Evidence - Percutaneous dilatational tracheotomy

  1. Literature summary

    Extraanatomical percutaneous access to the trachea is performed in one of two settings: As life-saving stat procedure in acute airway obstruction cephalad of the larynx, ideally penetrating the cricothyroid ligament between the thyroid and cricoid cartilages (coniotomy).

    Or, in most cases, as an elective procedure in intensive care for prolonged mechanical ventilation through a tracheal tube bypassing the oropharynx, hypopharynx and larynx.

    The tracheostomy (PDT) gained by puncture, probing with a guidewire and careful dilation serves to place a tracheotomy tube, equipped with a cuff and made of different materials, which facilitates airway hygiene. In one modification of this procedure, access is gained not by percutaneous puncture but surgical dissection.

    Tracheotomy is one of the oldest surgical procedures known to man.

    Historical medical reports include those of the Rig-Veda in Hinduism (1) two thousand years BC and by Galen (2 and 3).

    With the publications by Armand Trousseau (4) on his treatment of numerous diphtheria cases in childhood (5) the procedure became standardized in the first half of the 19th century.

    Statistical analysis of the periprocedural complications in tracheotomy yields rates widely differing between 5% and 48%, with no significant benefit favoring surgical dissection over PDT (6).

    When compared with the PDT usually performed outside of the OR, the study by M. Pauliny et al. in 2012, which updated this comparison in 109 patients and looked at secondary bleeding, infection and air leaks (pneumothorax, pneumomediastinum), demonstrated no statistical benefit for the more complex surgical procedure (7).

    Their results corresponded with those published in 1997 by Th. M. Treu and M. Koch (8), who paraphrased the percutaneous dilatational tracheotomy as “a new procedure” and reported 9 (unsuccessful) malpunctures in 112 cases investigated.

    In PDT, the most common acute problems resulting from malpunctures are vascular in nature. The paper by Peter Gilbey published in August of 2012 has compiled such errors and includes a severe nonvascular complication.

    Without a doubt, the procedure as painted by Henri de Toulouse-Lautrec (9) in 1891 (“Opération de trachéotomie”) should also be noted; it depicts none less than Docteur Jules Emile Péan. As can be seen, this must have been early on during the “opération” because in the painting he is deeply examining the mouth of the patient.

    There is discussion in the literature regarding the initial publication of the standardized procedure as we know it today; most experts favor the study by P. Ciaglia from 1985 (10) and its long-term follow-up of 1992 (11).

  2. Ongoing trials on this topic

  3. References on this topic

    1. Geldner, Karl Friedrich: Rig-Veda: Das heilige Wissen Indiens [The holy knowlwdge of India). Complete German translation of 1923; newly edited by Peter Michel. Marix Verlag, 2008.

    2. Galen: Opera Omnia. De methodo medendi. Edited and translated by R.J.Hankinson. Oxford: Clarendon Press, 1991.

    3. Kühn, Karl Gottlob: Claudii Galeni opera omnia-Klaudiu Galenu hapanta. Leipzig, 1821-1833.

    4. Mémoire sur un cas de trachéotomie pratiquée dans la période extrème de croup. In: Journal des connaissances médico-chirurgicales, 1835; 1:5, 41.

    5. Classics Of Pediatrics Library: Memoirs on diphtheria. From the writings of Bretonneau, Guersant, Trousseau, Bochut, Empis and Daviot. Facsimile Print, 1994.

    6. Nöckler, Veronika: Tracheotomie in der Intensivmedizin (Tracheotomy in intensive care); Fachweiterbildung des Pflegepersonals in Anaesthesie und Intensivmedizin am Klinikum Großhadern der LMU, München (training for nurses specialising in anesthesia and inteensive care, Grosshadern Medical Center of the LMU University, Munich, Germany), 1999.

    7. Pauliny M., Chrostova E., Mackova J., Liska M.,: Percutaneous dilation tracheostomy versus surgical tracheostomy in critically ill patients. Bratis Lek Listy, 2012; 113(7): 409-411

    8. Treu M., Knoch,M.: Die perkutane dilatative Tracheotomie als neues Verfahren in der Intensivmedizin: Durchführung, Vorteile und Risiken (Percutaneous dilatational tracheotomy as a new procedure in intensive care medicine: Procedure, benefits and risks). Dtsch med Wochensch 1997; 122(19): 599-605

    9. Rosen G.: A medical painting by Toulouse-Lautrec (opération de trachéotomie). J Hist Med Allied Sci. 1947 Summer; 2(3): 388.

    10. Ciaglia P., Firsching R., Syniec C. : Elective percutaneous dilatational tracheostomy. Chest 1985; 87: 715-719.

    11. Ciaglia P., Graniero KD: Percutaneous dilatational tracheostomy. Results and long-term follow-up. Chest 1992; 101: 464-467.

    12. Valentin A.: Tracheotomie bei Intensivpatienten: Ein kurzer Überblick mit offenen Fragen (Tracheotomy in ICU patients: A brief review with open issues). online Medicom-Verlag für Medizinische Kommunikation 5/07.

    13. Gilbey P.: Fatal complications of percutaneous dilatational tracheostomy. Am J Otolaryngol; Aug 2012

    14. Dulguerov P, Gysin C, Perneger TV, Chevrolet JC : Percutaneous or surgical tracheostomy; a meta-analysis. Crit Care Med 1999; 27:1617-1625

    15. Griffiths J, Barber VS, Morgan L, Young JD: Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. Brit Med J 2005; 330: 1243-1248

    16. Van Aken H, Reinhart K, Zimper M, Welte T: INTENSIVMEDIZIN (Intensive Care Medicine), 2.geb.Auflage 2007, Thieme-Verlag, Stuttgart,

    17. Bause H, Brause A, Schulte am Esch J: Indikation und Technik der PDT für Intensivpatienten (Indication and technique of PDT in ICU patients). Anästhesiol. Intensiv- und Notfallmedizin 30, 1995

    18. Gonfiotti, A et al: Development and Validation of a New Outcome Score in Subglottic Stenosis. Ann Thorac Surg Aug 2012.


Deng H, Fang Q, Chen K, Zhang X. Early versus late tracheotomy in ICU patients: A meta-analysis of

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