International Journal of Clinical Medicine, 2013, 4, 96-98
http://dx.doi.org/10.4236/ijcm.2013.42018 Published Online February 2013 (http://www.scirp.org/journal/ijcm)
Percutaneous Dilational Tracheostomy in the Emergent
Setting
Andrew McCague*, David T. Wong
Arrowhead Regional Medical Center, Colton, USA.
Received October 15th, 2012; revised November 15th, 2012; accepted November 22nd, 2012
ABSTRACT
Objective: Since its inception, the use of the percutaneous dilational tracheostomy (PDT) has been contraindicated in
the setting of an emergent airway. Emerging in the literature are several cases of successful emergent PDTs. Here we
present our experience with the use of PDT in managing emergent airways. Study Design: All patients who underwent
emergent PDT, using the Ciaglia Blue Rhino Introducer Set (Cook Critical Care, Bloomington, IN), in an academic
county hospital setting between February 2010 and May 2012 were included in the study. Electronic medical records
were reviewed for demographic and procedural data. Results: Twelve patients were included in the study with ages
ranging from 20 to 87 (mean 57) years old. The most common reason for emergent airway was trauma (7 patients), fol-
lowed by obstructing neck mass (2 patients), septic shock (2 patients), and angioedema (1 patient). Seven PDTs were
performed in the OR, four at bedside and one in the ER. Three of the 12 patients had emergent cricothyroidotomies in
place that malfunctioned, requiring emergent conversion. No patients suffered from short term complications. One pa-
tient developed a neck abscess at the site of the PDT one month post operatively, two patients had accidental decanula-
tion post operatively, and both were replaced without complication. Conclusions: PDT can be used in the emergent
setting in the hands of trained practitioners with minimal complications. A larger, prospective trial is needed to make
conclusi ons regar ding patie n t care.
Keywords: Percuta neous Di l at i onal Tracheostomy; Em ergent Airway; Trache ostomy
1. Introduction
The use of percutaneous dilational tracheostomy (PDT)
has continuously increased since its original description
by Ciagla in 1985. Since its inception, a need for an
emergent airway has been considered an absolute con-
traindication for the use of PDT. As case reports emerge,
a growing body of eviden ce is showing that PDT may be
an option in specific emergent conditions where an emer-
gent airway is necessary.
Most published articles consider cervical injury, pedi-
atric age < 8 years old, gross distortion of the neck anat-
omy, unidentifiable landmarks, visible large blood ves-
sels in the operative field, and need for emergent airways
as absolute contraindications, whereas obesity with a
short neck, coagulopathy, need for positive end-expira-
tory pressure of >20 cm of water, and evidence of infec-
tion in the soft tissues of the neck at the prospective sur-
gical site are relative contraindications [2].
With difficult intubations occurring in approximately
2% - 4% of all intubation attempts, the clinician may
expect emergent surgical airways to periodically be re-
quired [2]. Unfortunately, most clinicians find them-
selves performing these procedures for the first time in
an emergency, where failure rates and complication rates
are already high [2]. The opportunity to perfect the tech-
nique of PDT in an elective setting improves perform-
ance of this technique during an emergent setting.
Here we pr esen t our exper ience with th e use of PDT in
managing emergent airways.
2. Methods
All patients who underwent emergent PDT, using the
Ciaglia Blue Rhino Introducer Set (Cook Critical Care,
Bloomington, IN), in an academic county hospital setting
between February 2010 and May 2012 were included in
the study. Electronic medical records were reviewed for
demographic and procedural data. Emergent PDTs were
defined as PDTs performed in the setting of impending
airway loss. Short term complications were defined as
bleeding, malposition, pneumothorax, tracheal ring rup-
ture, conversion to open and procedural hypoxia. Long
term complications included bleeding, infection, acciden-
tal decanulation, granuloma formation, tracheal stenosis
*Corresponding a uthor.

Percutaneous Dilational Tracheostomy in the Emergent Setting 97
and dysphagia.
All PDTs were performed with attending physician at
bedside, most by a surgical resident. The Ciaglia Blue
Rhino Single Dilator Introducer Kit™ (Cook Medical
Inc., Bloomington, IN.) was used for all PDTs. All PDTs
were performed without bronchoscopic guidance with
local anesthetic and minimal or no sedation. Wh en avail-
able, positioning was confirmed with bronchoscopy.
Follow-up was determined from the most recent visit
as recorded in the electronic medical records. All data
was recorded and stored in an Excel (Microsoft, Red-
mond Wa.) spreadsheet for descriptive analysis.
3. Results
Results are presented in Table 1 below. Twelve patients
were included in the study with ages from 20 to 87 (mean
57) years old, length of stay 5 to 114 (mean 30) days and
body mass index from 23.9 to 47 (mean 31) kg/m2. The
most common reason for emergent airway was trauma (7
patients), followed by obstructing neck mass (2 patients),
septic shock (2 patients), and angioedema (1 patient).
Seven PDTs were performed in the OR, four at bedside
and one in the ER. Three of the 12 patients had emergent
cricothyroidotomies in place that malfunctioned, requir-
ing emergent bedside conversion.
No patients suffered from short term complications.
No patient expired or suffered anoxic brain injury as a
result of the procedure. One patient expired six days after
the PDT was performed due to a pulmonary embolism.
Six patients were discharged home, four sent to rehab,
one transferred to another hospital and one expired. Long
term complications occurred in 3 of the 12 patients. One
patient developed a neck abscess at the site of the PDT
one month post operatively, two patients had accidental
decanulation post operatively, and both were replaced
without complication. Follow-up ranged from 6 to 658
(mean 132) days.
4. Discussion
The use of PDT in the emergent setting has been revered
as an absolute contraindication since its inceptio n. As the
use of PDTs has grown in recent years, a growing body
of literature has shown the successful use of PDTs in the
emergent setting. Though PDTs will not replace the
emergent cricothyroidotomy, in specific clinical scenar-
ios we have shown that the PDT can be safely used in an
emergent setting avoiding the need for a future conver-
sion procedure.
In the above study, twelve patients underwent PDT in
an emergent setting without any sh ort term complications.
Three patients suffered from long term complications
though these are unlikely related to the emergent nature
of the procedure. One patient had a neck abscess and two
patients had accidental decanulation. These complica-
tions could equally have occurred if the procedure was
elective. One patient expired during the study due to a
Table 1. Descriptive data.
Case Age Sex Diagnosis Indication LocationLosFollow upDischarge Confirmation bronchoscopy Complication
1 78 M Cancer Difficult
intubation ER 5193 Home No Abscess
2 45 F Angioedema
Difficult
intubation OR 597 Home Yes Decanulation
3 50 M Trauma Obstructed
Cricothyroidotomy Bedside24659 Rehab Yes None
4 20 M Trauma Obstructed
cricothyroidotomy Bedside931 Home No Decanulation
5 80 M Trauma C-spine deformity,
difficult intubation OR 1528 Rehab Yes None
6 60 M Trauma Tracheal laceration
extending over ET tube OR 828 Home Yes None
7 87 F Trauma Difficult airway
impingment OR 19245 Hospital TransferYes None
8 61 M Sepsis Edematous airway,
failed intubation Bedside9080 Home Yes None
9 49 M Sepsis Obesity Bedside114158 Rehab Yes None
10 27 M Trauma GSW to Neck OR 66 Expired Yes None
11 62 M Cancer Larygneal Cancer,
Difficult intubation OR 3434 Home Yes None
12 66 F Trauma C-spine fx,
difficult airway OR 3131 Rehab Yes None

Percutaneous Dilational Tracheostomy in the Emergent Setting 98
pulmonary embolism, unrelated to the use of PDT. For
difficult to intubate patients with impending airway loss
PDT is a possible alternative to cricothyroidotomy when
performed in the hands of experienced practitioners.
In 2003, Ault et al. reported the largest series to date
of successful emergent PDT which included nine patients
with compromised airways. In their paper all nine pa-
tients were successfully intubated with a PDT technique
either in the Emergency Room or one of the Intensive
Care Units. They conclude that in specific clinical situa-
tions the PDT technique may play a role in management
of emergent surgical airways [2].
Because of the emergent nature of the PDTs per-
formed in our study, bronchoscopy was not used to guide
placement. When available we did, however, use bron-
choscopy to confirm placement. In the emergent situation,
neither time nor the presence of an existing endotracheal
tube permits the use of broncoscopy [2]. Bronchoscopic
guidance is a valuable but not essential adjunct to per-
formance of PDT and should not preclude use of this
procedure in the emergent setting [2]. In 2011, Jackson et
al. reported on 168 PDTs performed without broncho-
scopy compared with 78 performed with bronchoscopy
[3]. They found that there was not a difference in com-
plication rates between the two groups thus confirming
the practice of PDTs without bronchoscopy [3].
Though cricothyroidotomy is still the standard of care
for an emergent surgical airway; PDT has several advan-
tages. The major advantage of PDTs is the ab ility to gain
and maintain competence in an elective and controlled
setting [2]. This experience is invaluable as comfort and
familiarity with any procedure improves success and
reduces complications. Indications for performing a cri-
cothyroidotomy (surgical or needle) are very limited. It is
therefore extremely difficult to gain experience and be-
come confident in performing this procedure [4]. The
PDT also has the possibility of becoming a definitive
airway for the patient, there is no need to convert to a
formal tracheostomy as is the case with the cricothryroi-
dotomy. PDT has the advantage over an open surgical
technique as it is faster, can be performed under local
anesthesia at the bedside with or without prior airway
access, and can be performed within three minutes [4].
When comparing PDT to open tracheostomy, not only
is PDT a faster procedure but it has also been reported to
have lower complication rates. Moe et al. demonstrated
that PDTs have lower rates of pneumothorax, major
hemorrhage and laryngeal granulation when compared to
open tracheostomy [2]. They also reported an 8 minute
shorter procedure with PDTs as compared with open
tracheostomy [2]. Graha et al. also reported similar ad-
vantages with the use of PDT. They fou nd no significant
difference in major or minor complications when com-
paring PDT to open tracheostomy [2].
Our experience with PDT has shown that difficult air-
ways can be managed with this technique safely. In our
series of twelve patients, all attempted emergent PDTs
were performed successfully without loss of airway or
need to convert to a conventional tracheostomy. Though
additional trials are necessary to provide conclusive evi-
dence, we suggest that the use of PDTs may have a place
in the management of difficult and emergent airways.
5. Conclusion
Here we present twelve patients all who have undergone
PDT in an emergent setting. None of these patients suf-
fered short term complication s. Long term complications
seen in these patients were not related to the emergent
nature of the procedure. PDT can be used in the emergent
setting in the hands of trained practition ers with minimal
complications. Our study shows a lower complication
rate compared to previously published reports. A larger,
prospective trial is needed to make conclusions regarding
patient care.
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