Evaluation of a modified percutaneous tracheostomy technique without bronchoscopic guidance

Background: Most complications of percutaneous tracheostomy are caused by failure to cannulate the trachea and injury to surrounding structures. Traditionally, the procedure has been performed under bronchoscopic assistance, which may interfere with the patient's ventilation and is cumbersome. A modification was described in which the subcutaneous tissue is bluntly dissected with a hemostat down to the pretracheal fascia. The procedure is then performed with the guidance of the operator's finger, making the routine use of a bronchoscope no longer necessary. Methods: The modified technique was adopted and prospectively evaluated in an observational clinical study over a 30-month period, in patients requiring elective tracheostomy. Two commercially available kits were used. Patients' records were kept in files, and they were evaluated with regard to operative technique, complications, failure rate, and loss of airway. Results: During the study period, 61 procedures were attempted. All were performed at the patients' bedside. In three patients (4.9%), the percutaneous procedure was deferred due to anatomic problems: cervical venous engorgement in one patient, and difficulty in dissection in another patient. In the third patient, the trachea could be felt, but the tube provided with the kit was not long enough. One patient had persistent wound bleeding, requiring revision in the operating room. No other procedure-related complications were reported. In three patients, early tube dislodgement occurred, but whether this was related to the percutaneous procedure is debatable. Bronchoscopy was not used. Conclusions: The modified percutaneous technique, with limited surgical dissection, without routine bronchoscopy, is simple and safe when performed by physicians with surgical training. It is relatively easy to learn, saves costs and operating room burden, and carries low morbidity rates.