Fatal complications of

percutaneous dilatational
tracheostomy
Peter Gilbey, MDa,b,
aThe Otolaryngology, Head and Neck Surgery Unit, Ziv Medical Center, Zefat,
Israel bBar-Ilan University Faculty of Medicine in the Galilee, Israel
Received 19 June 2012
Tutor : dr.Erica Gilda Simanjuntak,SpAn
Presentated by : Astri Marsa Zulkarnaen,S.Ked

Abstract
Objectives

Fatal complications of percutaneous dilatational tracheostomy

(PDT) are rare and intraoperative fatal complications of PDT
even more so.

Methods

A review of all previously reported fatal complications of PDT was

conducted in order to :
examine the prevalent causes of death
to attempt to recommend measures designed to prevent similar fatal
complications in the future

Results

Cases of death during or following PDT in which the technique

is related to the cause of death have only been reported in a
small number of cases.
Almost all fatal complications of PDT result from vascular
injury.

Conclusions

Any vascular pulsation palpated over the tracheostomy site

mandates preoperative ultrasound or conversion to open
surgical tracheostomy.
History of previous neck surgery, radiotherapy or unclear
surgical anatomy should be regarded with caution.

 If a difficult intubation or procedure is anticipated it may

be preferable not to attempt PDT with a plan to convert to
surgical tracheostomy if necessary but instead to perform
surgical tracheostomy without attempting PDT.

Introduction
Percutaneous dilatational tracheostomy (PDT), first
described by Ciaglia et al in 1985, is the placement of a
tracheostomy tube without direct visualization of the trachea.

It is considered to be a minimally invasive procedure

that is performed in the intensive care unit or at the patient's
bedside.

Andvantages of PDT
The time required for performing bedside PDT is considerably
shorter than that required for performing an open
tracheostomy
eradication of scheduling difficulty associated with the
operating room and anesthesiology teams.

 Bedside PDT also prevents the necessity to transport critically

ill patients requiring intensive monitoring to the operating
room.
The cost of PDT is roughly half that of performing open
surgical tracheostomy.

A meta-analysis of five studies comparing PDT with surgical

tracheostomy found similar overall complication rates in the 2
groups.

Early

Late

Bleeding

development of granulation tissue

resulting in airway stenosis

infection

failure to decannulate or upper airway

obstruction with respiratory failure after
decannulation

Pneumothorax

tracheoesophageal fistula

technical failures and perioperative

hypoxia due to tube obstruction or
accidental decannulation

tracheomalacia

tracheal stenosis
tracheoinnominate artery fistula (TIF)

Case report
Name : Mrs.K
Age : 64th
Chief complaint : > left abdominal pain
> left flank pain
> dyspnea
on going disease : She was diagnosed as suffering from left pneumonia
and treated with intravenous antibiotics
Medical History : morbid obesity and elephantiasis of the lower limbs

intravenous antibiotics

patient became
unresponsive
Decided to
intubated ventilated transferred to the intensive care
unit

Attempts to wean the patient from mechanical ventilation were

unsuccessful
Requested

an elective tracheostomy
Due to the fact that the patient was morbidly obese with a short
neck, a joint decision by the Intensive Care unit and the
Otolaryngology, Head and Neck Surgery unit was made
transfer the patient to the operating room and not to perform a bedside
procedure

in the operating room, the patient was re-evaluated by an otolaryngologist

and an anesthesiologist
Despite the short neck the cricoid cartilage was palpated and a
decision was made

to increase airway safety, a Cook Airway Exchange Catheter (Cook Critical Care.
Bloomington, IN) was inserted into the trachea through the lumen of the
endotracheal tube via a swivel connector
Efficient jet ventilation through the airway exchange catheter was
demonstrated
Attempt PDT
unsuccessful

Attempts to reintubate over the tube exchanger

berhasil
unsuccessful

further attempts to reintubate the patient and to ventilate with a laryngeal

mask airway were ineffective
Final decision
attempt to perform an emergency
cricothyroidotomy
via the opening in the anterior neck were not observed
at any time during the procedure

The patient subsequently

desaturated and expired

Post mortem examination was requested but refused by the family.

Discussion
In a recent survey of the membership of the American
Academy of Otolaryngology, Head and Neck Surgery ,reported
the number of catastrophic tracheostomy complications they
had experienced during their career and the number of
complications leading to death or permanent disability

55% of respondents reported caring for at least one

patient with a catastrophic event related to a
tracheostomy, accidental decannulation (34.3%) or
bleeding (31.6%).

complication rates were

The most common Complications

Bleeding was the only early (within 1 week of the

procedure) complication found to be significantly
higher in the group of patients undergoing
percutaneous tracheostomy

Minor bleeding during the performance of PDT has been

reported to occur in fewer than 20% of cases.
Major bleeding occurred in fewer than 5% of cases and
was usually venous.
Catastrophic hemorrhage is rare, usually delayed and in
most cases is the result of a TIF

 Fatal complications of PDT have only been reported in a

small number of cases and fatal intraoperative
complications of PDT are even less common.
Almost all result from vascular injury.
One case of intraoperative death during PDT resulting
from loss of airway has been included in a national US
survey of tracheostomy-related catastrophic events.

Ultrasound (US)

improve the safety

profile of PDT

Intraoperative tracheal
endoscopy can reduce
the possibility of
paramedian or
extratracheal
placement of the
seeker needle

to identify the tracheal midline and the levels

of the tracheal cartilages and is also of benefit
in identifying overlying or vulnerable adjacent
structures such as the thyroid gland and
isthmus and blood vessels

Authors

Year of
Publication

Time of death

Cause of Death

Comments

Shlugman

2003

Intraoperative

Damage to right
subclavian artery

Ryan

2003

Intraoperative

Bleeding into
thyroid gland

Previous parathyroid surgery

McCormick

2005

Intraoperative

Damage to left
innominate artery

Right mastectomy with

postoperative radiotherapy

5 d postoperative

Damage to arch of
aorta

Low placement of tracheostomy

between 89 tracheal rings

Damage to
innominate vein
resulting in
bilateral
hemothorax

Low placement of tracheostomy

between 812 tracheal rings

Low placement of tracheostomy

between 89 tracheal rings

Previous thyroid surgery

22 d postoperative

Ayoub

2006

6 d postoperative

Damage to arch of
aorta

Das (personal
communication 2011
with author)

2011

Intraoperative
Intraoperative
Intraoperative

Major bleeding
Major bleeding
Airway loss

Present study

2012

Intraoperative

Airway loss

Fatal complication of PDT is

very rare
Case selection is of great
importance and patients with
previous neck surgery or
radiotherapy

Fatal complications of PDT are

extremely rare and usually result
from vascular injury

Conclusion

US and/or intraoperative tracheal endoscopy

seem to improve the safety profile of the
procedure but are logistically demanding and
probably not routinely required in all patients

if a difficult intubation or a difficult procedure

are anticipated, it may be preferable not to
attempt PDT with a plan to convert to surgical
tracheostomy if necessary, but instead to
perform surgical tracheostomy without
attempting PDT