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(Chest. 1999;116:1498.)
© 1999 American College of Chest Physicians

Percutaneous Dilational Tracheostomy Kits

Dean P. Sandifer, MD, FCCP

Watson Clinic, LLP, Lakeland, FL

Correspondence to: Dean P. Sandifer, MD, FCCP, Department of Adult Critical Care Medicine, Watson Clinic, LLP, 1600 Lakeland Hills Blvd, Lakeland, FL 33804

To the Editor:

I read with interest the article by Trottier and colleagues (May 1999)1 concerning percutaneous dilational tracheostomy (PDT) using the PDT kit manufactured by Smith Industries (Keene, NH). In the 24 PDTs cases performed by Trottier et al, the development of three postprocedure tension pneumothoraces, two requiring thoracotomy, and two inadvertent extubations is unheard of and completely unacceptable. We have completed scores of PDTs using this kit without a single tension pneumothorax, mainstem tracheostomy tube placement, or tracheostomy tube obstruction, and certainly without any patients requiring post-PDT thoracotomy. If all medical centers had complications of this frequency and severity, PDT would not be a viable option. I have no affiliation, or relationship, with any PDT manufacturer. I have expressed that the tapered Portex PDT tube (Smith Industries) offers a distinct advantage over the kit manufactured by Cook Inc. (Bloomington, IN) regarding the final step of tracheostomy tube insertion over a dilator.2

Contrary to the protocol of this study, we do not routinely utilize neuromuscular blockade during PDT. Inhibiting the cough and respiratory reflexes of the patients may well increase the incidence of posterior tracheal perforation. Cough can be an early warning sign that posterior tracheal pressure is excessive when using any PDT kit. Neuromuscular blockade also exacerbates the urgency of rare inadvertent extubation.

Although the use of adjunct of fiberoptic bronchoscopy (FOB) in the training for the performance of PDT is vital, many experienced operators perform PDT without FOB with far superior complication rates than in this study. The article’s focusing of attention on PDT catheter and guidewire positioning and stabilization is important. Also, as expressed in Dr. Ciaglia’s editorial,3 maintaining the noninserted end of each PDT dilator cephalad to the insertion end is likely to minimize trauma to the posterior tracheal wall.

In combination with techniques to prevent guidewire misplacement, some experienced operators purposely do not withdraw the existing endotracheal tube above the tracheostomy insertion site prior to PDT. The presence of the distal endotracheal tube at the PDT insertion site prevents tracheal collapse, lessens inadvertent extubation, and may well protect the posterior tracheal wall from perforation. With appropriate PDT tube sizing, there is ample tracheal lumenal area to accommodate both the tapered dilators and the distal end of the endotracheal tube.

References

  1. Trottier, ST, Hazard, PB, Sakabu, SA, et al (1999) Posterior tracheal wall perforation during percutaneous dilational tracheostomy. Chest 115,1383-1389[Abstract/Free Full Text]
  2. Sandifer, DP (1997) Pathologic changes of the trachea after percutaneous dilational tracheostomy. Chest 111,255-256[Free Full Text]
  3. Ciaglia, P (1999) Technique, complications, and improvements in percutaneous dilational tracheostomy. Chest 115,1229-1230[Free Full Text]




This Article
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Right arrow Articles by Sandifer, D. P.

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