Complications of bronchoscopically guided percutaneous dilational tracheostomy: beyond the learning curve

Objective: To assess the complication rate of bronchoscopically guided percutaneous dilational tracheostomy (PDT), with tracheal tube suture fixation and no elective tracheostomy tube exchange, after experience had been gained. Design: Prospective clinical study. Setting: Anaesthesiological ICU with mixed surgical and medical patients in a university hospital. Patients: Hundred thirty-three mechanically ventilated patients (mean age: 54.8 years, range: 13-87 years) with indication for PDT, many with thrombocytopenia and/or coagulation deficits. Interventions: Hundred thirty-six consecutive PDTs performed by residents under bronchoscopic guidance with stepwise dilation (n = 114, Ciaglia's conventional system) or conic dilation (n=22, "Blue Rhino" approach) and supervision of experienced staff anaesthesiologists. Tracheostomy tubes were fixed to the skin with a suture and no routine exchange of tracheostomy tubes was performed. Complications were categorised and the results were also compared to an earlier prospective study. Results: The incidence of tracheostomy tube-related complications (hypoxaemia, cannula misplacement, accidental decannulation, cuff rupture and hernia, or posterior tracheal wall lesion) was low (0.7%) and significantly less (6.2%, p=0.01) than in our earlier study. No patient died of PDT-associated complications. We recorded four (2.9%) clinically, relevant bleeding episodes. Insertion of tracheal tubes was easy or only, moderately difficult in 86.7%. Conclusion: With experience in performing PDT, fixation of the tracheal cannula, and omission of routine change of tracheostomy tubes complication rate of PDT is low.