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Clinical Investigations in Critical Care |

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

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
Text Size: A A A
Published online

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

Figures in this Article

Tracheostomy is one of the oldest surgical operations in medical history and reference to this procedure can be found 3,500 years ago.1The percutaneous dilational tracheostomy (PDT) was described in 19572and modified in 1985 by Ciaglia et al.3The complication rates and economics of tracheostomy tube insertion via the percutaneous technique compare favorably and are possibly superior to those with standard operative tracheostomy tube insertion. Frequently quoted complication rates associated with PDT range from 3.9 to 31% compared with 6 to 66% for standard operative tracheostomy tube insertion.418

The study described in this article originated as a quality improvement exercise evaluating the complication rate of PDT at our institution. Unexpectedly, a high rate of posterior tracheal wall perforation was documented. The purpose of this study was twofold: (1) to describe the complication of posterior tracheal wall injury and perforation associated with PDT and (2) to determine the potential mechanism of posterior wall injury using a swine and cadaver model.

Part 1

The clinical study was performed in a medical-surgical ICU at a tertiary teaching community hospital. The Human Subjects Committee approved the study and informed consent was obtained from each patient or next of kin. The operating surgeons (B.R.T., S.A.S., J.H.L.) had experience and training in the technique of PDT using the Ciaglia Percutaneous Tracheostomy Introducer Set (Cook Inc; Bloomington, IN). The operating surgeons had performed 35 percutaneous tracheostomies prior to this study with the Per-fit Percutaneous Tracheostomy Kit (Smiths Industries Medical Systems Portex Inc; Keene, NH). Medical-surgical ICU patients > 18 years of age requiring tracheostomy were eligible for the study. Patients with any of the following criteria were excluded from the study: (1) prior tracheostomy; (2) hemorrhagic disorders (platelet count < 50,000, or prothrombin time international normalized ratio ≥ 2.0, or activated partial thromboplastin time ≥ 1.5 times the control value); (3) marked anatomic abnormalities of the trachea or cervical region; (4) clinical evidence of infection at the trachea puncture site; (5) clinical suspicion or evidence of increased intracranial pressure; or (6) the need for an emergent airway. The study was divided into three phases: preprocedural, intraprocedural, and postprocedural phases. During the preprocedural phase, patients were sedated with fentanyl and midazolam and received muscle relaxation with pancuronium. The patients were monitored with continuous pulse oximetry, received 1.0 atmosphere of oxygen, and were provided an adequate minute ventilation. Demographic data were collected and a bronchoscopic inspection of the airway was performed. A nonvideoscopic bronchoscope was used throughout the clinical portion of the study. During the intraprocedural phase, the endotracheal tube was positioned in the subglottic space and a tracheostomy tube was inserted percutaneously using the Per-fit Percutaneous Tracheostomy Kit. The tracheostomy tube used in this study was a custom Portex tracheostomy tube (SIMS Portex Inc; Keene, NH) with a tapered flush opening. Immediately following the tracheostomy tube insertion, the bronchoscopist visualized the airway through the tracheostomy tube. During the postprocedure phase, patients underwent fiberoptic inspection of the airway twice a day for the first 96 h posttracheostomy and then daily up to 14 days posttracheostomy tube insertion. A 2-mm fiberoptic endoscope (Angiolaz; Rockingham, VT) was used to perform the daily inspections. Clinical markers of tracheostomy tube obstruction (increased airway pressures, decreased tidal volumes, development of air trapping or autopositive end-expiratory pressure, the ease of inserting a suction catheter) were assessed daily. Complications were recorded.

Part 2

This portion of the study was performed at the Medical Education and Research Institute, Memphis, TN. The protocol was approved by the Academic Review Board at the Medical Education and Research Institute. The investigator (P.B.H.) who performed the animal and cadaver study had vast experience in PDT. A veterinary technician prepared the 57-kg swine. Premedication was achieved with azaperone, 8 mg/kg, followed by general anesthesia with pentobarbital sodium and nitrous oxide. Intubation with a 10-mm tube was performed and mechanical ventilation was instituted (Hallowell Ventilator; Pittsfield, MA). The swine was positioned in the right lateral decubitus position and a thoracotomy was performed to subsequently expose the carina and mainstem bronchi. After creating a small opening in the right mainstem bronchus, a fiberoptic bronchoscope was inserted through and secured to the bronchus. A fiberoptic bronchoscope was inserted via the endotracheal tube, and the endotracheal tube was positioned above the tracheostomy tube insertion site. The PDT was video recorded proximally and distally from the insertion site. Insertion of the tracheostomy tubes was performed using two PDT kits, the Ciaglia Percutaneous Tracheostomy Introducer Set and the Per-fit Percutaneous Tracheostomy Kit.

PDT was performed with both kits according to standard guidelines. Subsequently, both kits were used without stabilizing the guidewires or guiding catheters during insertion of the dilators or tracheostomy tubes. The Per-fit Percutaneous Kit was then used while the guiding catheter was intentionally withdrawn into the dilator. Tracheostomy tube insertions were performed through separate sites. The animal was killed and the trachea and larynx were removed for inspection.

The cadaver was intubated with an 8-mm endotracheal tube positioned in the subglottic space, and a bronchoscope was inserted to record the tracheostomy tube insertion. The tracheostomy tubes were inserted as described above and video recordings were made. Anatomic inspection of the airway was performed.

Part 1

Twenty-four medical-surgical ICU patients underwent PDT. Sixteen patients were male and 8 patients were female. The average age of the patients was 47 ± 22 years. Complications occurred in 7 (29%) of 24 patients and were as follows: 3 (12.5%) posterior tracheal wall perforations with tension pneumothoraces, 2 inadvertent extubations, 1 tracheostomy tube obstruction, and 1 right mainstem tracheostomy tube placement.

The three patients with posterior tracheal wall perforations had similar clinical presentations. During the PDT, the guidewire and guiding catheter were documented to be intratracheally located via bronchoscopic inspection. Serial dilations were performed without difficulty. During the serial dilations and tracheostomy tube insertion, the tracheal lumen was noted to collapse temporarily, compromising approximately 90% of the airway. Following the tracheostomy tube insertion, bronchoscopic evaluation through the tracheostomy tube found that the distal end of the tube was occluded with soft tissue. The tracheostomy tubes were removed and successfully reinserted intratracheally in two of the three patients. The other patient was reintubated orally with an endotracheal tube. Shortly after the tracheostomy tubes were removed, the patients developed subcutaneous emphysema, decreased arterial saturation, and decreased breath sounds in one side of the chest. Tension pneumothoraces were documented radiographically in two of the three patients. Thoracostomy tubes were inserted in all three patients, followed by immediate clinical improvement. Bronchoscopy performed through the two tracheostomy tubes and one endotracheal tube revealed 1.0- to 2-cm posterior tracheal wall perforations immediately proximal to the tracheostomy/endotracheal tube cuff. The tracheostomy tubes and endotracheal tube needed to be withdrawn 1.0 to 1.5 cm to adequately visualize the perforations. Two of the three patients underwent thoracotomy with primary repair of the perforations. The other patient was treated conservatively and died of nontracheostomy-related causes.

The patients inadvertently extubated prior to tracheostomy tube insertion were reintubated without incident. The tracheostomy tube obstruction noted at the time of tube insertion in one patient was related to the patient’s thick neck. A standard endotracheal tube placed through the tracheostomy tube track was required to provide an adequate airway for this patient. One patient sustained a right mainstem tracheostomy tube insertion that was relieved by changing the tracheostomy tube. The postprocedural phase assessed the airway patency of the tracheostomy tubes. None of the patients experienced clinically significant airway obstruction.

Part 2

PDT was performed successfully in the swine and cadaver model with both kits adhering to the recommended technique. No trauma to the posterior tracheal wall was noted with either kit. Subsequently, both kits were then used to inset a tracheostomy tube via the percutaneous technique without stabilizing the guidewire and guiding catheter. The guiding catheters were documented to move approximately 5 cm along the posterior wall with both kits resulting in a 5-cm laceration through the mucosal surface and involving but not through the underlying muscular layer (Fig 1, center). When the guiding catheter was not stabilized during the procedure using the Per-fit Percutaneous Tracheostomy Kit, the guiding catheter retracted partially but not completely into the dilators. If the guiding catheter was intentionally retracted into the dilator during PDT, the dilator would perforate the posterior tracheal wall (Fig 2). It should be noted that the investigator perceived that excessive force was required to insert the tracheostomy tube when the perforation occurred. The ridge on the guiding catheter from the Ciaglia Percutaneous Tracheostomy Introducer Set prevented the dilators from advancing over the guiding catheter onto the guidewire. The same observations were reproduced in the cadaver model. It should be noted that in the cadaver, the introduction of the tracheostomy tube and dilator perforated the posterior wall when the guiding catheter was withdrawn into the dilator assembly. This was accomplished without the perception of excessive force.

Current literature supports PDT in the critically ill ICU patients.19Economic profiles favor tracheostomy tube insertion via the percutaneous technique when compared with standard operative tracheostomy tube insertion.2021 The complication rate associated with standard operative tracheostomy tube insertion ranges from 6 to 66%, compared with the complication rate of 3.9 to 31% for the PDT. Although high, the complication rate associated with PDT in the current study falls within the reported range. The data describing the complication rates associated with PDT have largely been from retrospective and cohort studies and not from prospective, randomized, controlled trials. The three small randomized trials have found in favor of PDT.2224 Similar to other surgical techniques, PDT has a learning curve, and the associated complications appear to decrease as the operator gains experience.25

The clinical portion of this study reaffirms that bronchoscopic guidance should be used during PDT and may provide a mechanism for early detection and prevention of complications. The patients sustaining posterior tracheal wall perforation, premature extubation, right main stem tracheostomy tube insertion, and tracheostomy tube obstruction due to anatomic circumstances were recognized with the aid of the bronchoscope.

The complication most disturbing in this study was the high rate (12.5%) of posterior tracheal wall perforation. The actual incidence of posterior tracheal wall perforation during PDT is difficult to ascertain from the literature but appears to be < 1%.2628 Bronchoscopic evaluation of the airway during and following PDT is required to assess for posterior tracheal wall perforation or injury. Most studies reporting the complications associated with PDT have not included bronchoscopic evaluation of the airway. Thus, the reported incidence of posterior tracheal wall perforation may underestimate the true incidence of posterior tracheal wall perforation associated with PDT. Only three other investigators have bronchoscopically documented posterior tracheal wall perforation during PDT.2628 Similar to our findings, patients with posterior tracheal wall perforations frequently sustained pneumothoraces requiring tube thoracostomy decompression. The posterior tracheal wall perforations that occurred during this study were documented at the time of tracheostomy insertion. To adequately visualize the 1.0- to 1.5-cm perforations, the bronchoscopist needed to withdraw the tracheostomy tubes and endotracheal tube approximately 1 to 2 cm. If this maneuver were not performed, the posterior tracheal wall perforation would have been unrecognized.

What is not uncommonly reported in the literature are the complications of subcutaneous emphysema, mediastinal emphysema, and pneumothorax following a PDT. We can only speculate whether some of these patients may have had an injury to the posterior tracheal wall.

Due to the high incidence of posterior tracheal wall perforation, the investigators terminated the clinical portion of the study. After the PDT in each of the patients with a posterior perforation, the investigator noted that the guidewire had been kinked during the procedure. The investigators believed that the dilators were advancing over the guiding catheter intratracheally onto the guidewire during the procedure (Fig 1, bottom). The guidewire alone would not provide enough support to keep the dilator within the trachea and therefore predispose to perforation of the posterior tracheal wall. To test this theory, a protocol to evaluate PDT in an animal and cadaver model was developed.

An anesthetized swine underwent PDT as described in the “Materials and Methods,” section. Adhering to suggested technique, the investigators performed PDT using the Per-fit Percutaneous Tracheostomy Kit and the Ciaglia Percutaneous Tracheostomy Introducer Set. The tracheostomy tubes were inserted without complications, including no trauma or perforation to the posterior tracheal wall.

Without stabilizing the guidewire and guiding catheter (incorrect technique) during PDT using both kits, the guiding catheter was documented to move approximately 5 cm along the posterior tracheal wall creating a 5-cm laceration through the mucosa involving but not through the underlying muscle. Posterior tracheal wall perforation did not occur. Although posterior tracheal wall mucosal laceration has been reported during PDT, the mechanism of injury until now has been unclear. The clinical significance of this laceration has not been evaluated, but the implications regarding the technique of PDT are clear: to avoid or minimize injury to the posterior tracheal wall during PDT, the guiding catheter and guidewire should be stabilized firmly throughout the procedure. Therefore, two individuals are required to correctly and safely perform PDT: one of the individuals performing the tracheostomy and the other dedicated to stabilizing the guidewire and guiding catheter.

The guiding catheters in the Per-fit Percutaneous Tracheostomy Kit and Ciaglia Percutaneous Tracheostomy Introducer Set differ in one aspect; the guiding catheter from the Ciaglia Percutaneous Tracheostomy Introducer Set has a ridge on the distal end. The ridge on the guiding catheter was added to prevent injury to the posterior tracheal wall but data supporting this statement have not been published to our knowledge.29 During the dilations and tracheostomy tube insertions, the ridge on the guiding catheter from the Ciaglia Percutaneous Tracheostomy Introducer Set prevented the dilators from advancing over the catheter. However, when the guiding catheter from the Per-fit Tracheostomy and guidewire were not stabilized, the guiding catheter allowed the dilators to advance partially. The dilators did not fully advance over the guiding catheter unless the guiding catheter was intentionally withdrawn into the dilators. When the dilators were advanced over the guiding catheter and the tracheostomy tube was inserted, a posterior tracheal wall perforation was documented to occur (Fig 2). The investigator noted that the pressure to create a posterior tracheal wall perforation was in excess of the usual pressure required to insert the insert the tracheostomy tube adhering to suggested technique. The same results were reproduced in the cadaver model. The force required to create a posterior tracheal wall perforation in the cadaver was not excessive and may reflect the decreased tissue strength nonviable tissue.

Based on the observations from the swine and cadaver models, the mechanism of posterior tracheal wall perforation observed in the clinical portion of this study may have been related to inadequate stabilization of the guidewire and guiding catheter during tracheostomy tube insertion.

This two-part study provides an in-depth evaluation of an infrequently reported complication associated with PDT. The mechanism and possible prevention of posterior tracheal wall perforation/injury during PDT are presented. Several salient points warrant emphasis: (1) Bronchoscopic guidance during PDT is recommended, including bronchoscopic inspection of the airway through the newly placed tracheostomy tube. The use of bronchoscopic guidance during PDT assures that the guidewire and guiding catheter are located intratracheally. Adherence to proper technique and documentation that the guidewire and accompanying guiding catheter are located intratracheally may minimize the risk of posterior tracheal wall perforation/injury during PDT. (2) Stabilization of the guidewire and guiding catheter during PDT is critical to prevent or minimize posterior tracheal wall injury or perforation. It was not possible to perforate the swine or cadaver posterior tracheal wall during PDT when this technique was followed. (3) A ridge on the distal end of the guiding catheter prevents the dilators from advancing over the guiding catheter onto the guidewire.

The clinical and experimental data generated from this observational study provide the clinician with an improved understanding regarding the technique of PDT, specifically how to avoid or minimize the complication of posterior tracheal wall injury. Owing to the findings documented in this study, the Per-fit Percutaneous Tracheostomy Kit is currently undergoing modification to include a guiding catheter with a ridge (Fig 3).

For editorial comment see page 1229.

Figure Jump LinkFigure 1. Top, A: guidewire and guiding catheter appropriately positioned in the trachea. Center, B: dilator correctly advanced following the guiding catheter. If the guidewire and guiding catheter are not stabilized, then they may move along the posterior tracheal wall resulting in injury (arrow). Bottom, C: the guiding catheter is withdrawn into the dilator (incorrect technique) during dilation. The arrow displays the point of potential tracheal wall injury.Grahic Jump Location
Figure Jump LinkFigure 2. Airway removed from the swine demonstrating the posterior tracheal wall perforation (clamp through the perforation).Grahic Jump Location
Figure Jump LinkFigure 3. Modified Smiths Industries Medical Systems guiding catheter with a ridge (arrow).Grahic Jump Location

ACKNOWLEDGMENT: This article is dedicated to the late Dr. Hazard whose contributions to this project and to medicine have been invaluable.

Alberti, PW (1984) Tracheotomy versus intubation: a 19th cen-tury controversy.Ann Otol Rhinol Laryngol93,333-337. [PubMed]
 
Sheldon, CH, Pudenz, RH, Tichy, FY Percutaneous tracheostomy.JAMA1957;165,2068-2070. [CrossRef]
 
Ciaglia, P, Firsching, R, Syniec, C Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report.Chest1985;87,715-719. [PubMed]
 
Meade, JW Tracheostomy–its complications and their management: a study of 212 casesN Engl J Med1961;265,519-523. [PubMed]
 
Glas, WW, King, OJ, Lui, A Complications of tracheostomy.Arch Surg1962;85,56-63. [PubMed]
 
Dugan, DJ Tracheostomy: present day indications and techniques.Am J Surg1963;106,290-306. [PubMed]
 
Yarington, CT, Frazer, JP Complications of tracheostomy.Arch Surg1965;91,652-655. [PubMed]
 
Chew, JY, Cantrell, RW Tracheostomy: complications and their management.Arch Otolaryngol1972;96,538-545. [PubMed]
 
Skaggs, JA, Cogbill, CL Tracheostomy: management, mortality, complications.Am Surg1969;35,393-396. [PubMed]
 
Rogers, LA Complications of tracheostomy.South Med J1969;62,1469-1500
 
Dane, TEB, King, EG A prospective study of complications after tracheostomy for assisted ventilation.Chest1975;67,398-404. [PubMed]
 
Stock, MC, Woodward, CG, Shapiro, BA, et al Perioperative complications of elective tracheostomy in critically ill patients.Crit Care Med1986;14,861-863. [PubMed]
 
Graham, JS, Mulloy, RH, Sutherland, FR, et al Percutaneous versus open tracheostomy: a retrospective cohort outcome study.J Trauma1996;42,245-250
 
van Heurn, LW, Goei, R, dePloeg, I, et al Late complications of percutaneous dilatational tracheotomy.Chest1996;110,1572-1576. [PubMed]
 
Cobean, R, Beals, M, Moss, C, et al Percutaneous dilatational tracheostomy: a safe, cost-effective bedside procedure.Arch Surg1996;131,265-271. [PubMed]
 
Petros, S, Englemann, L Percutaneous dilatational tracheostomy in a medical ICU.Intensive Care Med1997;23,630-634. [PubMed]
 
Van Heerden, PV, Webb, SAR, Power, BM, et al Percutaneous dilational tracheostomy–a clinical study evaluating two systems.Anaesth Intensive Care1996;24,56-59. [PubMed]
 
Toursarkissian, B, Zweng, TN, Kearney, PA, et al Percutaneous dilational tracheostomy: report of 141 cases.Ann Thorac Surg1994;57,862-867. [PubMed]
 
Anderson, HL, Barlett, RH Elective tracheotomy for mechanical ventilation by the percutaneous technique.Clin Chest Med1991;12,555-560. [PubMed]
 
Fernandez, L, Norwood, S, Roettger, R, et al Bedside percutaneous tracheostomy with bronchoscopic guidance in critically ill patients.Arch Surg1996;131,129-132. [PubMed]
 
Barba, CA, Angood, PB, Kauder, DR, et al Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure.Surgery1995;118,879-883. [PubMed]
 
Hazard, P, Jones, C, Benitone, J Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy.Crit Care Med1991;19,1018-1023. [PubMed]
 
Friedman, Y, Fildes, J, Mizock, B, et al Comparison of percutaneous and surgical tracheostomies.Chest1996;110,480-485. [PubMed]
 
Holdgaard, HO, Pedersen, J, Jensen, KE, et al Percutaneous dilational tracheostomy versus conventional surgical tracheostomy: a clinical randomised study.Acta Anesthesiol Scand1998;42,545-550
 
Hazard, PB Further refinement of percutaneous tracheostomy technique.Intensive Care Med1994;20,466-467. [PubMed]
 
Hazard, PB, Garrett, HE, Adams, JW, et al Bedside percutaneous tracheostomy: experience with 55 elective procedures.Ann Thorac Surg1988;46,63-67. [PubMed]
 
Hill, BB, Zweng, TN, Maley, RH, et al Percutaneous dilational tracheostomy: report of 356 cases.J Trauma1996;40,238-244
 
Berrouschot, J, Oeken, J, Schneider, D Perioperative complications of percutaneous dilational tracheostomy.Laryngoscope1997;107,1538-1544. [PubMed]
 
Marx, WH, Ciaglia, P, Graniero, KD Some important details in the technique of percutaneous dilatational tracheostomy via the modified seldinger technique.Chest1996;110,762-766. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Top, A: guidewire and guiding catheter appropriately positioned in the trachea. Center, B: dilator correctly advanced following the guiding catheter. If the guidewire and guiding catheter are not stabilized, then they may move along the posterior tracheal wall resulting in injury (arrow). Bottom, C: the guiding catheter is withdrawn into the dilator (incorrect technique) during dilation. The arrow displays the point of potential tracheal wall injury.Grahic Jump Location
Figure Jump LinkFigure 2. Airway removed from the swine demonstrating the posterior tracheal wall perforation (clamp through the perforation).Grahic Jump Location
Figure Jump LinkFigure 3. Modified Smiths Industries Medical Systems guiding catheter with a ridge (arrow).Grahic Jump Location

Tables

References

Alberti, PW (1984) Tracheotomy versus intubation: a 19th cen-tury controversy.Ann Otol Rhinol Laryngol93,333-337. [PubMed]
 
Sheldon, CH, Pudenz, RH, Tichy, FY Percutaneous tracheostomy.JAMA1957;165,2068-2070. [CrossRef]
 
Ciaglia, P, Firsching, R, Syniec, C Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report.Chest1985;87,715-719. [PubMed]
 
Meade, JW Tracheostomy–its complications and their management: a study of 212 casesN Engl J Med1961;265,519-523. [PubMed]
 
Glas, WW, King, OJ, Lui, A Complications of tracheostomy.Arch Surg1962;85,56-63. [PubMed]
 
Dugan, DJ Tracheostomy: present day indications and techniques.Am J Surg1963;106,290-306. [PubMed]
 
Yarington, CT, Frazer, JP Complications of tracheostomy.Arch Surg1965;91,652-655. [PubMed]
 
Chew, JY, Cantrell, RW Tracheostomy: complications and their management.Arch Otolaryngol1972;96,538-545. [PubMed]
 
Skaggs, JA, Cogbill, CL Tracheostomy: management, mortality, complications.Am Surg1969;35,393-396. [PubMed]
 
Rogers, LA Complications of tracheostomy.South Med J1969;62,1469-1500
 
Dane, TEB, King, EG A prospective study of complications after tracheostomy for assisted ventilation.Chest1975;67,398-404. [PubMed]
 
Stock, MC, Woodward, CG, Shapiro, BA, et al Perioperative complications of elective tracheostomy in critically ill patients.Crit Care Med1986;14,861-863. [PubMed]
 
Graham, JS, Mulloy, RH, Sutherland, FR, et al Percutaneous versus open tracheostomy: a retrospective cohort outcome study.J Trauma1996;42,245-250
 
van Heurn, LW, Goei, R, dePloeg, I, et al Late complications of percutaneous dilatational tracheotomy.Chest1996;110,1572-1576. [PubMed]
 
Cobean, R, Beals, M, Moss, C, et al Percutaneous dilatational tracheostomy: a safe, cost-effective bedside procedure.Arch Surg1996;131,265-271. [PubMed]
 
Petros, S, Englemann, L Percutaneous dilatational tracheostomy in a medical ICU.Intensive Care Med1997;23,630-634. [PubMed]
 
Van Heerden, PV, Webb, SAR, Power, BM, et al Percutaneous dilational tracheostomy–a clinical study evaluating two systems.Anaesth Intensive Care1996;24,56-59. [PubMed]
 
Toursarkissian, B, Zweng, TN, Kearney, PA, et al Percutaneous dilational tracheostomy: report of 141 cases.Ann Thorac Surg1994;57,862-867. [PubMed]
 
Anderson, HL, Barlett, RH Elective tracheotomy for mechanical ventilation by the percutaneous technique.Clin Chest Med1991;12,555-560. [PubMed]
 
Fernandez, L, Norwood, S, Roettger, R, et al Bedside percutaneous tracheostomy with bronchoscopic guidance in critically ill patients.Arch Surg1996;131,129-132. [PubMed]
 
Barba, CA, Angood, PB, Kauder, DR, et al Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure.Surgery1995;118,879-883. [PubMed]
 
Hazard, P, Jones, C, Benitone, J Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy.Crit Care Med1991;19,1018-1023. [PubMed]
 
Friedman, Y, Fildes, J, Mizock, B, et al Comparison of percutaneous and surgical tracheostomies.Chest1996;110,480-485. [PubMed]
 
Holdgaard, HO, Pedersen, J, Jensen, KE, et al Percutaneous dilational tracheostomy versus conventional surgical tracheostomy: a clinical randomised study.Acta Anesthesiol Scand1998;42,545-550
 
Hazard, PB Further refinement of percutaneous tracheostomy technique.Intensive Care Med1994;20,466-467. [PubMed]
 
Hazard, PB, Garrett, HE, Adams, JW, et al Bedside percutaneous tracheostomy: experience with 55 elective procedures.Ann Thorac Surg1988;46,63-67. [PubMed]
 
Hill, BB, Zweng, TN, Maley, RH, et al Percutaneous dilational tracheostomy: report of 356 cases.J Trauma1996;40,238-244
 
Berrouschot, J, Oeken, J, Schneider, D Perioperative complications of percutaneous dilational tracheostomy.Laryngoscope1997;107,1538-1544. [PubMed]
 
Marx, WH, Ciaglia, P, Graniero, KD Some important details in the technique of percutaneous dilatational tracheostomy via the modified seldinger technique.Chest1996;110,762-766. [PubMed]
 
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