1. The document compares the surgical and percutaneous dilational tracheostomy (PCDT) procedures for creating a tracheostomy from 2013-2015. 2. 51 total cases were performed, with 2 patients requiring conversion to an open procedure due to bleeding complications with PCDT. 3. PCDT was found to be a safe and effective alternative to the open surgical procedure with comparable late complications but lower early bleeding risks and cost.

1. PCDT
A COMPARITIVE AUDIT OF A
NEW PROCEDURE IN MICU
2013 - 2015

2. What is “Tracheostomy”
 The word “tracheotomy” is derived from the Latin
“trachea” and “tomein” (to make an opening).
 Tracheostomy is an operative procedure that creates a
surgical airway in the cervical trachea .
 Traditionally surgical or open has been the choice, off
late percutaneous or PCDT is used more often.

3. History
 One of the oldest surgeries pictured even in Egyptian tablets in 3600 BC
 100 BC: Asclepiades described tracheostomy incision .
 100 AD: Antyllus described the familiar tracheotomy:
a horizontal incision between 2 tracheal rings.
 1546: Brasavola published account of tracheotomy for tonsillar obstruction.
He was the first person known to have actually performed the successful
operation.
 1561-1636: Sanctorius was the first to use a trocar and cannula. He left the
cannula in place for 3 days
 1718: Lorenz Heister coined the term tracheotomy
 1909: Chevalier Jackson codified indications & techniques for modern
tracheotomy

4. Anatomy
• Major blood vessels
(carotids, innominate art,
jugular veins)
• Thyroid gland
• Esophagus
• Larynx
• Nerves (Rec.Laryngeal)
• Cervical spine

5. Anatomy contd

6. Tracheotomy Indications
To bypass obstruction
- Tumors (of oropharynx, larynx, upper trachea)
- Infections (epiglottitis,diphteria, etc)
- Bilateral Vocal Cord Paralysis
- Trauma (maxillofacial fractures,severe bleeding, airway
obstruction,laryngeal injuries.)
- Edema (tongue, laryngopharynx)
- Intubation failure
- Foreign body obstruction
- Subglottic or tracheal stenosis

7. Tracheotomy Indications
• Need for prolonged ventilatory support
• Neuromuscular diseases paralyzing or weakening chest
muscles & diaphragm.
• Cervical sp cord injuries +/- respiratory muscle paralysis.
• Aspirations related to CNS, muscular or sensory impairement
• To reduce anatomic dead space and increase the chance for
mechanical ventilation withdrawal
• Better ease of nursing care & Pulmonary toileting.
• To improve the patient`s comfort & quality of life (easier
toileting,ability to speak & eat increase the mobility)

8. Advantages
• Less irritation of nose, mouth and throat.
• Mouth care is much easier to perform thus indirectly
preventing VAP.
• The patient is able to cough up mucus as the airway
distance is shorter.
• Lesser amount of sedation so early withdrawal from
ventilation and decreased risk of VAP.
• Ability to speak and if the patient can swallow,he can
eat and drink

9. Disadvantages
• Procedure related complications - primarily
bleeding.
• Pneumothorax , pneumomediastinum,injuries to
other structures.
• A scar will remain visible on the neck –very
minimal or not seen in PCDT.
• Delayed complications – tracheal
stenosis,tracheal stricture and tracheo-
esophageal fistula.

10. Surgical techniques
open procedure

11. Surgical or open procedure

12. Surgical techniques
open procedure

13. History of PCDT
 1955, Shelden et al - first attempt with cutting trocar
into the trachea.
 1985, Ciaglia et al -percutaneous dilational
tracheostomy (PCDT)
 1989, Schachner et al - Rapitrach
 1990, Griggs et al - the guidewire dilating forceps (GWDF)
 2000s – Ciaglia blue rhino.

14. Percutaneous approach

15. 2013-2015
2013 – 10 CASES
2014 – 25 CASES
2015 – 16 CASES
(TILL DATE)
TOTAL NO OF CASES - 51
1.HEAD INJURY -
18
2.POISONINGS -
06
3.SEPSIS - 06
4.CVA - 03
5.MENINGITIS - 03
6.0THERS -

17. THE PROCEDURE….

20. THE RESULTS…….
1. Two of the pts had conversions to open tracheostmy
2.Two patients had moderate to severe bleeding .
3.Two patients performed under assisted technique.
4 One patient had bilateral pneumothorax pneumomediastinum.
5.Two patients devoloped late onset tracheo-oesophageal fistula(*both
ventilated for more than a month)
6 One pt came back with mild tracheal stenosis. (H1N1 –recovered
with dilatation)

21. Complications –Immediate.
• Apnea due to transient loss of ventilatory support must .
• False root / false passage.
• Bleeding
• Pneumothorax or pneumomediastinum
• Damage to the vocal cords (direct)
• Injury to adjacent structures: recurrent laryngeal nerves,
the great vessels, and the esophagus.
• Post-obstructive pulmonary edema
• Hypotension
• Arrhythmia

22. Complications - Early
• Early bleeding: This is usually the result of increased blood
pressure as the patient emerges from anesthesia and begins
to cough.
• Plugging with mucus
• Tracheitis
• Cellulitis or local infection.
• Tube displacement
• Subcutaneous emphysema
• Atelectasis

23. Complications - Late
• Bleeding - tracheoinnominate fistula
• Tracheo- and laryngomalacia
• Stenosis
• Tracheoesophageal fistula
• Tracheocutaneous fistula
• Granulation
• Scarring
• Failure to decannulate

25. CONCLUSIONS
1. PCDT – a safe and effective method in trained hands
2. Cost effective requires less assistants,less time(3-5min avg )
3. Early /immediate complications are known but self limiting
(primarily bleeding)
4. Late complications comparable with surgical method, incidence
is LESS.
5. Overall a safe method. Use of USG and bronchoscopy to be
encouraged when available.

27. THAT’S FAIRY TALE…….
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