ABSTRACT
I. Introduction Tracheostomy as an open surgical procedure in the operating room setting has spanned over a hundred years and has been the classic standard approach to the airway. Percutaneous dilational tracheostomy (PDT) performed at the patient bedside has gained wide acceptance over the past 15 years (1-5). The actual technique continues to be modified, but has been based on the Seldinger technique with percutaneous serial dilations over a guidewire. Ciaglia described the initial percutaneous technique in 1985. This was further modified with the Ciaglia Blue Rhino technique using a single dilation technique. Other methods of performing PDT have been described (1-5). Most recently, a balloon dilation technique has been introduced to establish the tracheostomy tract. The advantages of PDT include the ability to avoid transport of a critically ill patient to an operating room setting, reduction in the time between decision to perform tracheostomy and actual procedure, avoiding the need for general anesthesia, as well as cost savings by avoiding the need for operative room and its personnel. There has also been more interest in performing bedside open surgical tracheostomy (OST) to provide similar benefits. PDT is a natural extension of OST but is a less invasive technique that can be performed by otolaryngologists, general surgeons, interventional pulmonologists, and intensivists. PDT has proven to be safe and effective, with complication rates comparable to OST. In many centers patient evaluation and PDT occur the same day (6-16). While the debate over patient selection, timing to tracheostomy, as well as technique continues, the need for proper procedural training along with development of a complimentary team is universally agreed upon by all specialties performing this procedure (17-20). Tracheostomy has become a relatively common procedure, provided in both the surgical and medical critical care settings for those patients requiring prolonged mechanical ventilator support because of a wide range of diseases such as extensive burns, trauma, significant cardiopulmonary disease, and neuromuscular or neurologic disease. As the general population ages, the severity of critical illness increases along with the likelihood of prolonged respiratory failure. The transition from translaryngeal intubation to tracheostomy is expected to optimize pulmonary toilet and patient comfort, to reduce the need for sedation, and to potentially improve the process of weaning from mechanical ventilator. The ability to identify specific patient parameters upon initial presentation with acute respiratory failure, which indicate those most likely to require mechanical ventilator support for greater than seven days, may allow for more timely transition to tracheostomy. Presently, there is increasing clinical data on the benefits of early
tracheostomy in specific medical patient populations as well as in the trauma and surgical arena (17-28). Animal and clinical models have been developed to assess the impact of early versus late tracheostomy on the airway. Mucosal damage to the proximal airways and vocal cords can occur within three to seven days of endotracheal tube placement. Despite these data there is no universal agreement on timing to tracheostomy. There is a growing trend to advise early tracheostomy when mechanical ventilator support is anticipated for greater than 10 days. This chapter will focus on PDT with a review of the airway anatomy and procedural technique, patient selection, indications with special population considerations, contraindications, distinguishing early versus late complications, and timing of tracheostomy.
