Posterior tracheal wall perforation during percutaneous dilational tracheostomy - An investigation into its mechanism and prevention

Objectives: Part 1: To describe the complication of posterior tracheal wall injury and perforation associated with the pel cutaneous dilational trache ostomy (PDT). Part 2: To determine the mechanism of posterior tracheal wall injury during PDT, Design: Prospective observational study. Subjects: Pall. 1: Medical-surgical ICU patients requiring tracheostomy. Pa rt 2: Swine and cadaver models, Interventions: Part 1: Consecutive medical-surgical ICU patients undergoing tracheostomy tube insertion via the percutaneous dilation technique with b ronchoscopic guidance were enrolled in the study, Demographic data and comp lications were recorded, Part 2: Tracheostomy tubes were inserted via the p ercutaneous dilational technique in the swine model with concomitant bronch oscopic video recording from the proximal and distal airways, Tracheostomy tubes were inserted via the percutaneous dilational technique in the cadave r model followed by anatomic inspection of the airway, Results: Part 1: Seven (29%) of 2 1 medical-surgical ICU patients sustained complications associated with PDT, Three patients (12.5%) sustained poster ior tracheal wall perforations followed by the development of tension pneum othoraces, Part 2: The swine model demonstrated that posterior tracheal wal l perforation may occur during PDT when the guiding catheter is withdrawn i nto the dilating catheters, Five-centimeter posterior tracheal wall mucosal lacerations occurred when the guidewire and the guiding catheter were not properly stabilized during PDT, Conclusion: Percutaneous dilational tracheostomy was associated with a 29% complication rate in this observational study. Of concern was the high rate (12.5%) of posterior tracheal wall perforation. The swine and cadaver mode ls suggest that posterior tracheal mall injury or perforation may occur if the guidewire and guiding catheter are not properly stabilized. To avoid po sterior tracheal wall injury, the guidewire and guiding catheter should be firmly stabilized during PDT.