In the excellent article in this issue of CHEST
by Trottier and colleagues (see page 1383), the cause of posterior
tracheal wall perforation during percutaneous dilatational tracheostomy
(PDT) was studied clinically and in swine and cadaver experiments.
In the clinical part of the study, the authors were justifiably
concerned about the high incidence of posterior tracheal wall trauma.
Twenty-four medical-surgical ICU patients underwent PDT using the
Per-fit Percutaneous Tracheostomy Kit (Smiths Industries Medical
Systems Portex Inc; Keene, NH), and three patients suffered posterior
tracheal wall perforations. After the PDT in each of the patients with
a posterior perforation, the investigator noted that the guidewire had
been kinked during the procedure. It was believed that the dilators
were advancing over the guiding catheter intratracheally onto the
guidewire during the procedure (see Trottier and colleagues, Fig
1, bottom). The guidewire
alone, according to the investigators, would not provide enough support
to keep the dilator within the trachea, and therefore predispose to
perforation of the posterior tracheal wall. I agree. The authors, to
test this theory, developed a protocol to evaluate the PDT in animal
and cadaver models. This was excellent reasoning, and good animal and
cadaver models were developed.