Bedside percutaneous tracheostomy: Prospective evaluation of a modification of the current technique in 100 patients

Percutaneous dilatational tracheostomy (PDT) is being increasingly used. Co ncerns have been raised as to its safety, especially when it is done at the bedside. A prospective evaluation was conducted of 100 consecutive, unsele cted critically ill patients with PDT. The mean intensive care unit (ICU) s tay before PDT was 12 days. One surgeon performed PDT alone (5 cases) or as sisted residents (95 cases) in all operations; 84 were performed at the ICU bedside. Only the first six patients were taken to the operating room sole ly for tracheostomy. A modified technique was used: (1) the endotracheal tu be was left in place during sequential dilations; (2) dilators were inserte d in a 60-degree cephalad orientation to the skin and directed caudally aft er penetration of the anterior tracheal wall; (3) a digit was inserted thro ugh the tracheal opening to guide withdrawal of the endotracheal tube to th e level of the vocal cords; and (4) size 8 tracheostomy cannulas were inser ted over 28F dilators. The average time from skin incision to insertion of the tracheostomy tube was 12 minutes (< 10 minutes, 41 patients; 10 to 15 m inutes, 37 patients; > 15 minutes, 22 patients). Sixty-five percent had unf avorable anatomic conditions due to spinal precautions or diffuse neck edem a. Postoperative complications occurred in four patients; surgical emphysem a after tracheal lacerations in three, cannula dislodgment in one, All comp lications were successfully managed without an operation by tube exchange ( n = 3) or observation (n = 1); there was no procedure-related mortality. Fo rty patients were available for long-term follow-up (6-18 months after trac heostomy) by telephone; one had persistent hoarseness without respiratory d ifficulty. We concluded that bedside PDT is safe and easy to teach when per formed with a technique that ensures correct instrumentation.