Some Important Details in the Technique of Percutaneous Dilatational Tracheostomy via the Modified Seldinger Technique

The percutaneous dilatational tracheostomy can be performed with a low complication rate if several important technical details are followed. This study delineates our experience and recommends changes in the operative technique. Patients requiring tracheostomy were selected for percutaneous dilatational tracheostomy based on previously reported criteria. The procedures were performed routinely in the ICU unless there was another reason to transport the patient to the operating room. The patients were monitored with an ECG and pulse oximetry. End−tidal CO2 and ventilator settings were noted by the respiratory therapist. The airway was controlled using the bronchoscope and manually by the respiratory therapist. Adjustments were made in respiratory rate or tidal volume as indicated by an increase in end−tidal CO2. We report our experience with 254 patients who underwent percutaneous dilatational tracheostomy. We prospectively recorded intraoperative, early, and late complications. From our personal experience of 170 cases previously reported and 84 recent cases, we find that there are several important technical details in performing the procedure that will minimize complications. (1) Use of a deflated endotracheal tube cuff and increased tidal volume on the ventilator to compensate for lost minute volume and maintain normal PaCO2; (2) an adequate skin incision to more easily palpate and identify the tracheal cartilages; (3) directing the cannula needle caudally to properly identify the tracheal air column; (4) a new ridge on the 8F Teflon guiding catheter to prevent injury to the posterior tracheal wall by the dilators; (5) there is a danger of partially withdrawing the double guide when removing the largest−sized dilators that are usually tightly grasped by the tissues; (6) use of a single cannula flexible tracheostomy tube and a longer tracheostomy tube when indicated; (7) a double swivel connection and flexible tubing to connect the patient to the ventilator to lessen trauma to the stoma; (8) fenestrated tracheostomy tubes allow talking in conscious patients; and (9) use of a disposable end−tidal CO2 monitor and bronchoscope to confirm intratracheal position of the endotracheal tube while performing the procedure and proper placement of the tracheostomy tube on completion of the procedure. Using these principles, minor complications occurred in 6.5% of the patients and major complications occurred in 1.5% of the patients, with a mortality rate of 0.39%.