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Clinical Investigations in Critical Care |

Posterior Tracheal Wall Perforation During Percutaneous Dilational Tracheostomy*: An Investigation Into Its Mechanism and Prevention

Steven J. Trottier, MD; Patrick B. Hazard, MD, FCCP; Stanley A. Sakabu, MD; Jeffery H. Levine, MD; Bryan R. Troop, MD; Jeffery A. Thompson, MD; Richard McNary, RN, RRT
Author and Funding Information

*From St. John’s Mercy Medical Center (Drs. Trottier, Sakabu, Levine, Troop, and Thompson), St. Louis University, St. Louis, MO; the Medical Education and Research Institute (Dr. Hazard), University of Tennessee Center for the Health Sciences, Memphis, TN; and the Smiths Industries Medical Systems Portex, Inc. (Mr. McNary), Keene, NH. Supported in part by a grant from Smiths Industries Medical Systems (SIMS) Portex Inc, Keene, NH. Richard McNary is a full-time employee of SIMS Portex Inc. Patrick Hazard was a part-time paid consultant of SIMS Portex Inc.

Correspondence to: Steven J. Trottier, MD, St. John’s Mercy Medical Center, Department of Critical Care Medicine, Tower B 5007, 621 S New Ballas Rd, St. Louis, MO 63141; e-mail: critcare@inlink.com



Chest. 1999;115(5):1383-1389. doi:10.1378/chest.115.5.1383
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Objectives: Part 1: To describe the complication of posterior tracheal wall injury and perforation associated with the percutaneous dilational tracheostomy (PDT). Part 2: To determine the mechanism of posterior tracheal wall injury during PDT.

Design: Prospective observational study.

Subjects: Part 1: Medical-surgical ICU patients requiring tracheostomy. Part 2: Swine and cadaver models.

Interventions: Part 1: Consecutive medical-surgical ICU patients undergoing tracheostomy tube insertion via the percutaneous dilation technique with bronchoscopic guidance were enrolled in the study. Demographic data and complications were recorded. Part 2: Tracheostomy tubes were inserted via the percutaneous dilational technique in the swine model with concomitant bronchoscopic video recording from the proximal and distal airways. Tracheostomy tubes were inserted via the percutaneous dilational technique in the cadaver model followed by anatomic inspection of the airway.

Results: Part 1: Seven (29%) of 24 medical-surgical ICU patients sustained complications associated with PDT. Three patients (12.5%) sustained posterior tracheal wall perforations followed by the development of tension pneumothoraces. Part 2: The swine model demonstrated that posterior tracheal wall perforation may occur during PDT when the guiding catheter is withdrawn into 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 models suggest that posterior tracheal wall injury or perforation may occur if the guidewire and guiding catheter are not properly stabilized. To avoid posterior tracheal wall injury, the guidewire and guiding catheter should be firmly stabilized during PDT.

Abbreviations: PDT = percutaneous dilational tracheostomy

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