Percutaneous dilational tracheostomy: current techniques and evidence of safety

Tracheostomy has transitioned from being the complete domain of surgeons, as described by Chevalier Jackson in early 20th century, to a procedure shared by intensivists and interventional pulmonologists in form of percutaneous dilatational tracheostomy. This procedure is commonly performed in intensive care units to facilitate long-term mechanical ventilation for chronic respiratory failure, but other less frequent indications also exist. The commonly practiced techniques for percutaneous dilational tracheostomy rely on passage of tools over a guidewire, with the Ciaglia technique being the most popular and having the best safety profile. Adjunctive techniques include use of bronchoscopy, bedside ultrasonography, and laryngeal mask airway (LMA). In properly selected patients, percutaneous dilational tracheostomy carries a good safety profile, but some patient characteristics may increase the risk of complications; thus, the procedure is complimentary to surgical tracheostomy (ST) and not a complete replacement. Bedside ultrasound and bronchoscopy are routinely available instruments in most intensive care units, although there is limited evidence of improved safety with these adjuncts. In properly selected patients, percutaneous dilational tracheostomy can be a safe and cost-effective alternative to ST.