Tracheostomy, as a procedure for producing secure airway access, has been performed and refined for over 4,000 years. Although historically challenged with frequent complications, advances in technology and minimally invasive techniques have made percutaneous tracheostomy (PCT) a popular procedure in many intensive care units (ICUs). PCT is a less invasive method for performing tracheostomy at the bedside that has become a practical alternative to standard open tracheostomy in recent years for critically ill patients requiring prolonged mechanical ventilation.

Tracheostomy for patients who cannot be weaned from mechanical ventilation has four major benefits:

Soon after Seldinger described other needle over wire techniques in 1953, percutaneous tracheal access was described in 1955 by Shelden.¹ Unfortunately, this first approach of gaining access by guiding a cutting trocar into the trachea with the use of a slotted needle resulted in unacceptably high complications, as the technique for assuring a continuous airway during the procedure was not technically adequate. Since that time, the technique has been substantially refined. In 1969, Toye and Weinsten² described a technique using a recessed blade and single tapered dilator advanced into trachea over guiding catheter. Then, in 1985, Ciaglia et al³ described the first completely percutaneous technique for PDT, using the Seldinger guidewire exchange technique followed by serial dilations with sequentially larger dilators. Later, in 2000, Byhahn et al⁴ described the Ciaglia Blue Rhino, a modified Ciaglia technique using a single step dilation with a hydrophilically coated curved dilator. These methods, in their original form or in various hybrid forms, have proven to be convenient and effective alternatives to traditional open surgical tracheostomy and remain the most common method in use for PCT.

In both Europe and the United States, PCT has become quite popular. In a survey in Germany, Kluge et al⁵ found that 86% of ICUs routinely perform PCT; 93% were performed at the bedside by intensivists. Although other variations have been described, the Ciaglia-based techniques have remained most prevalent, and when combined with bronchoscopic guidance, have been shown to be safe and efficacious in the hands of nonsurgeons, primarily intensivists.⁶

PCT improves health delivery efficiency and clinical outcomes. Most importantly, early evidence suggests that PCT reduces inherent risks and operational costs involved in transporting critically ill patients to the operating room (OR), avoiding expensive OR and anesthesia time.

Most of the patients for whom PCT is used are those in ICUs who are slow to wean from mechanical ventilators. Because such patients have already had an endotracheal tube (ETT) placed, active airway management for this procedure is not required, though sedation and assurance of airway patency during the procedure are necessary. Some authors have described the replacement of the ETT with a laryngeal mask airway for ventilation during this procedure, in order to improve visualization of tracheal structures,⁷ though most PCTs are performed with the ETT still in place.

Long-term complications related to classic tracheostomy appear to be reduced with this technique. However, as with any surgical procedure, acute complications may still occur, and the critical care physician or anesthesiologist taking care of ICU patients must be aware of these.⁸

Trottier⁹ evaluated PCT performance prospectively in a cohort of patients in a medical-surgical ICU, and described a 12.5% incidence of posterior tracheal perforation with subsequent development of tension pneumothorax. Other authors have suggested that this is a rare complication.¹⁰,¹¹ Wise et al¹² reported the results of a survey sent to both trainees and established anesthesiologists in the United Kingdom. Acute complications described by this population included pneumothorax, hemorrhage, and loss of the airway or misplacement of the tracheostomy tube. However, a meta-analysis of studies comparing the open and percutaneous techniques described a lower frequency of postoperative bleeding and overall postoperative complications, as well as a
comparable frequency of overall procedural complications.¹⁰ More recently, Higgins and Puthakee¹¹ conducted a meta-analysis of trials comparing the open tracheostomy technique with PCT and reported no difference in overall complications; there was a trend toward fewer complications with PCT, including fewer wound infections and episodes of unfavorable scarring. However, PCT appears to increase the risk of both extraluminal placement of the tube and inability to recannulate the airway if decannulation occurs. Diaz-Reganon et al¹³ described an incidence of early postprocedural complications of 0.8% and late postprocedural complications of 1.1% with this procedure.

PCT can be performed by experienced operators without bronchoscopic guidance.¹⁴ This procedure can be safely carried out on patients with coagulopathy or thrombocytopenia,¹⁵ in patients with cervical fractures,¹⁶ and obese patients.¹⁷