Preventing posterior tracheal wall perforation in percutaneous dilational tracheotomy.

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A 49-year-old woman with a history of orthotopic liver transplantation was admitted to the intensive care unit for respiratory failure requiring intubation. She had graft-versus-host disease and fever of unknown origin. The patient was unable to be weaned from ventilator support, so the ICU team performed a percutaneous dilational tracheotomy (PDT) under bronchoscopic guidance. The guidewire, dilator, and guiding catheter were visualized within the tracheal lumen throughout the procedure, but on insertion of the tracheotomy tube, the tube position within the lumen could not be confirmed. The patient was reintubated, and a standard operative tracheotomy was performed. During this procedure, the PDT catheter was noted within the left sidewall of the trachea, and the opening was extended to the anterior tracheal wall; a tracheotomy tube was placed through this incision.

Over the next 12 hours, the patient developed massive subcutaneous emphysema and pneumomediastinum. An upper aerodigestive perforation was suspected, and emergency endoscopy was performed. Direct tracheoscopy revealed the presence of a 4-cm perforation in the posterior tracheal wail (figure, A). No communication or injury to the esophagus was evident. The patient was treated by advancing a reinforced endotracheal tube distal to the injury site to prevent the egress of air into the mediastinum (figure, B). Postoperatively, the patient's subcutaneous emphysema and pneumomediastinum resolved, and she experienced no further respiratory sequela. However, she died of hepatic and renal failure during her hospitalization.

Tracheotomy is one of the oldest surgical operations in medical history, dating back 3,500 years. PDT was first described by Shelden et al (1) in 1957, and a modified version was published in 1985 by Ciaglia et al. (2) The complication rates associated with PDT (range: 3.9 to 31%) compare favorably with those of standard operative tracheotomy (range: 6 to 66%). (3) Posterior tracheal wall perforations during PDT are generally uncommon, although they have exceeded 12% in some series. (4) PDT may also be more economical.

Even though PDT is less invasive, it still requires the same diligence as operative tracheotomy. To prevent complications, the surgeon must adhere to strict procedural guidelines. Based on the results of prospective randomized clinical and cadaveric studies, the most common cause of posterior tracheal wall laceration is poor technique--specifically, a failure to stabilize the guidewire and guiding catheter during the procedure. (5) Without proper stabilization, the guiding catheter can lacerate the mucosa and underlying musculature as it moves along the posterior tracheal wall. When the dilator is advanced over the catheter onto the guidewire, the guidewire alone does not provide enough support to keep the dilator within the trachea, and this lack of support predisposes to perforation of the posterior tracheal wall. Adherence to proper technique by stabilizing the guidewire, guiding catheter, and dilator will decrease the risk of complications. Ideally, two persons should be used to safely perform the procedure--one dedicated to stabilizing the guidewire and catheter and the other to performing the tracheotomy.

References

(1.) Shelden CH, Pudenz RH, Tichy FY. Percutaneous tracheotomy. JAMA 1957; 165(16):2068-70.

(2.) Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest 1985;87(6):715-19.

(3.) Hazard P, Jones C, Benitone J. Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med 1991;19(8):1018-24.

(4.) Friedman Y, Fildes J, Mizock B, et al. Comparison of percutaneous and surgical tracheostomies. Chest 1996; 110(2):480-5.

(5.) Trottier SJ, Hazard PB, Sakabu SA, et al. Posterior tracheal wall perforation during percutaneous dilational tracheostomy: An investigation into its mechanism and prevention. Chest 1999; 115(5): 1383-9.

Jason S. Hamilton, MD; Sofia Avitia, MD; Ryan F. Osborne, MD, FACS 

From the Osborne Head and Neck Institute, Los Angeles