title: Posterior tracheal wall perforation during percutaneous dilational tracheostomy: an investigation into its mechanism and prevention.
abstract: OBJECTIVE
  Part 1: To describe the complication of posterior tracheal wall injury and perforation associated with the percutaneous dilational tracheostomy (PDT). Part 2: To determine the mechanism of posterior tracheal wall injury during PDT.
  
  
  METHODS
  Prospective observational study.
  
  
  METHODS
  Part 1: Medical-surgical ICU patients requiring tracheostomy. Part 2: Swine and cadaver models.
  
  
  METHODS
  Part 1: Consecutive medical-surgical ICU patients undergoing tracheostomy tube insertion via the percutaneous dilation technique with bronchoscopic guidance were enrolled in the study. Demographic data and complications were recorded. Part 2: Tracheostomy tubes were inserted via the percutaneous dilational technique in the swine model with concomitant bronchoscopic video recording from the proximal and distal airways. Tracheostomy tubes were inserted via the percutaneous dilational technique in the cadaver model followed by anatomic inspection of the airway.
  
  
  RESULTS
  Part 1: Seven (29%) of 24 medical-surgical ICU patients sustained complications associated with PDT. Three patients (12.5%) sustained posterior tracheal wall perforations followed by the development of tension pneumothoraces. Part 2: The swine model demonstrated that posterior tracheal wall perforation may occur during PDT when the guiding catheter is withdrawn into the dilating catheters. Five-centimeter posterior tracheal wall mucosal lacerations occurred when the guidewire and the guiding catheter were not properly stabilized during PDT.
  
  
  CONCLUSIONS
  Percutaneous dilational tracheostomy was associated with a 29% complication rate in this observational study. Of concern was the high rate (12.5%) of posterior tracheal wall perforation. The swine and cadaver models suggest that posterior tracheal wall injury or perforation may occur if the guidewire and guiding catheter are not properly stabilized. To avoid posterior tracheal wall injury, the guidewire and guiding catheter should be firmly stabilized during PDT.
authors.affiliation: Department of Critical Care Medicine, St. John's Mercy Medical Center, St. Louis University, MO 63141, USA. critcare@inlink.com
authors.forename: S J
authors.initials: SJ
authors.lastname: Trottier
authors.forename: P B
authors.initials: PB
authors.lastname: Hazard
authors.forename: S A
authors.initials: SA
authors.lastname: Sakabu
authors.forename: J H
authors.initials: JH
authors.lastname: Levine
authors.forename: B R
authors.initials: BR
authors.lastname: Troop
authors.forename: J A
authors.initials: JA
authors.lastname: Thompson
authors.forename: R
authors.initials: R
authors.lastname: McNary
mesh_terms: D000818:Animals; D001999:Bronchoscopy; D004106:Dilatation / Q000009:adverse effects; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D011030:Pneumothorax / Q000209:etiology; D011446:Prospective Studies; D011677:Punctures; D013552:Swine; D014132:Trachea / Q000293:injuries*; D014139:Tracheostomy / Q000009:adverse effects* / Q000295:instrumentation; D014950:Wounds, Penetrating / Q000175:diagnosis / Q000209:etiology*