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Percutaneous dilational tracheostomy (PDT), also referred to as bedside tracheostomy, is the placement of a tracheostomy tube without direct surgical visualization of the trachea. This is considered a minimally invasive, bedside procedure that may be easily performed in the intensive care unit or at the patient’s bedside – with continuous monitoring of the patient’s vital signs.
Two critically important preoperative criteria for PDT are:
- The ability to hyperextend the neck
- Presence of at least 1 cm distance between cricoid cartilage and suprasternal notch ensuring that the patient will be able to be reintubated in case of accidental extubation
Patients should not be considered for this procedure if they are:
- Children (younger than 12 years of age)
- Patients with severe coagulopathies
There are several different systems and approaches for PDT. Following are brief descriptions:
Ciaglia (method used at Hopkins)
With this technique, there is no sharp dissection involved beyond the skin incision. The patient is positioned and prepped in the same way as for the standard operative tracheostomy. General anesthesia is administered and all steps are done under bronchoscopic vision.
Shachner (Rapitrac) system
- Skin incision is made and the pretracheal tissue is cleared with blunt dissection.
- Endotracheal tube is withdrawn enough to place the cuff at the level of the glottis.
- Endoscopist places the tip of the bronchoscope such that the light from its tip shines through the surgical wound.
- Operator enters the tracheal lumen below the second tracheal ring with an introducer needle.
- The tract between the skin and the tracheal lumen is then serially dilated over a guidewire and stylet.
- A tracheostomy tube is placed under direct bronchoscopic vision over a dilator.
- Placement of the tube is confirmed again by visualizing the tracheobroncial tree through the tube.
- Tube is secured to the skin with sutures and the tracheostomy tape.
- We routinely use Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer Tray.
After making a small skin incision, the surgeon passes a dilator tracheotome over the guidewire into the trachea to dilate the tract fully in one step. The tracheotome has a beveled metal core with a hole through its center that accommodates a guidewire. Once inside the trachea, the tracheotome is dilated. A conventional tracheostomy cannula, fitted with a special obturator, is passed through the tracheal opening. The dilator and obturator are then removed.
Translaryngeal tracheostomy (Fantoni’s technique)
Unlike the other techniques, the initial puncture of the trachea is carried out with the needle directed cranially and the tracheal cannula inserted with a pull-through technique along the orotracheal route in a retrograde fashion. The cannula is then rotated downward using a plastic obturator. The main advantage of Fantoni’s tracheostomy is the minimal amount of skin incision required, with practically no bleeding observed. It should be noted that the procedure can only be carried out under endoscopic guidance, and rotating the tracheal cannula downward may pose a problem – demanding that the surgeon have more experience.
Advantages of PDT
Although there is a learning curve to the technique of PDT, it is relatively easy to learn. The learning curve may be overcome by performing a number of supervised procedures. Other advantages include:
- Time required for performing bedside PDT is considerably shorter than that for an open tracheostomy
- Elimination of scheduling difficulty associated with operating room and anesthesiology teams for critical care patients
- PDT expedites the performance of the procedure because critically ill patients who would require intensive monitoring to and from the operating room need not be transported
- Cost of performing PDT is roughly half that of performing open surgical tracheostomy due to the savings in operating room charges and anesthesia fees
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