Clinical review: Percutaneous dilatational tracheostomy

Tracheostomy is one of the oldest surgical procedures, described in ancient books of medicine [1]. The standard operative tracheostomy technique presented by Jackson [2] remains little changed more than 100 years on. Several tracheostomy techniques have been described as percutaneous [3,4]. A technique of performing percutaneous dilatational tracheostomy (PDT) over a guidewire was first described by Ciaglia in 1985. It is increasingly being performed in intensive care units (ICUs) at the bedside. The Ciaglia technique, including its modifications, has become the most widely used procedure for the performance of PDT.In the first part of this review we consider general issues related to PDT. In the second section we focus on evidence-based recommendations, using the best available evidence, regarding issues such as modifications to PDT procedures designed to enhance patient safety and timing of performance in the ICU [5]. We conducted searches of Medline, the National Electronic Library for Health, the Cochrane Database of Systematic Reviews and the TRIP Database for reports published between 1985 and 2005, using the following key words: 'percutaneous', 'tracheostomy' and 'intensive care units'. Evidence is weighted according to the following rating scheme: A = scientific evidence provided by randomized and nonrandomized trials with statistically significant results; B = scientific evidence provided by observational studies or by controlled trials; and C = expert opinion with lack of scientific evidence.Various types of PDT techniques are available. They all require puncture of the trachea and insertion of a guidewire into the trachea. The puncture should be performed between the first and second or between the third and fourth tracheal rings. There is some evidence that a puncture between the third and fourth tracheal rings is associated with the lowest rate of accidental injury to aberrant vessels and other structures if there are anatomical abnormalities [6]. In mo