Sie sind auf Seite 1von 7

m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 1 5 8 e1 6 4

Available online at


j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / m j a fi

Original Article

Real time ultrasound-guided percutaneous

tracheostomy: Is it a better option than
bronchoscopic guided percutaneous tracheostomy?

Gp Capt Parli Raghavan Ravi a,*, Wg Cdr M.N. Vijay b

Senior Advisor (Anaesthesiology), 5 Air Force Hospital, C/O 99 APO, India
Classified Specialist (Anaesthesiology), Command Hospital Air Force, Bangalore, India

article info abstract

Article history: Background: The purpose of this study was to evaluate the efficacy of ultrasound guided
Received 2 February 2014 percutaneous tracheostomy (USPCT) and bronchoscopic guided percutaneous tracheos-
Accepted 26 January 2015 tomy (BPCT) and the incidence of complications in critically ill, obese patients.
Available online 12 March 2015 Methods: Seventy four consecutive patients were included in a prospective study and
randomly divided into USPCT and BPCT. Incidence of complications, ease and efficacy were
Keywords: compared in obese USPCT (n ¼ 38)and BPCT (n ¼ 36). Results are expressed as the median
Percutaneous tracheostomy (25the75th percentile) or number (percentage).
Ultrasound Results: The median times for tracheostomy were 12 min (9e14) in USPCT patients and
Bronchoscopic 18 min (12e21.5) in BPCT (p ¼ 0.05). The overall complication rate was higher in BPCT than
USPCT patient group (75% vs. 321%, p < 0.05). Most complications were minor (hypotension,
desaturation, tracheal cuff puncture and minor bleeding) and of higher number in the
BPCT. Ultrasound-guided PCT was possible in all enrolled patients and there were no
surgical conversions or deaths.
Conclusions: This study demonstrated that real US-guided PCT is a favourable alternative to
BPCT with a low complication rate and ease, thus proving more efficacious. A US exami-
nation provides information on cervical anatomy, vasculature etc. and hence modifies and
guides choice of the PCT puncture site.
© 2015, Armed Forces Medical Services (AFMS). All rights reserved.

effective alternative to open, surgical tracheostomy.1e3 Bron-

Introduction choscopic guidance during PT may be useful in avoiding injury
to surrounding structures, high placement of the tube, injury
Percutaneous tracheostomy (PT) is a commonly performed to the posterior tracheal wall and in confirming endotracheal
bedside procedure in the Intensive Care Unit (ICU). Several placement.4,5 However, bronchoscopy does not identify the
studies have demonstrated that PCT is a safe and cost- vascular structures or the thyroid gland in the neck region and

* Corresponding author.
E-mail address: (P.R. Ravi).
0377-1237/© 2015, Armed Forces Medical Services (AFMS). All rights reserved.
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 1 5 8 e1 6 4 159

thus does not prevent complications linked to local organ

lesions (punctured vessels or a punctured thyroid) and in
patients with acute brain injury, it can cause acute elevations
in intracranial pressure.
Preliminary reports suggest that sonographic delineation
of anatomy prior to tracheal puncture during PT may help
prevent bleeding from pre-tracheal vascular structures and
placement of the tracheal tube above the first tracheal ring.6,7
The use of real-time ultrasonography, with actual visualiza-
tion of the needle path up to the anterior tracheal wall should
further decrease the risk of puncture above the first tracheal
ring as well as the risk of injury to surrounding structures and
the posterior tracheal wall. Real-time guidance during PT
may be particularly useful when factors that increase the
technical difficulty of the procedure (morbid obesity, difficult
anatomy, cervical spine precautions) are present. However,
to the best of our knowledge, there are no published data
comparing the US guided and bronchoscopic guided percu-
taneous tracheostomy. Hence, the objectives of our study Fig. 1 e Longitudinal view of the Ultrasound of the neck.
were to compare the efficacy of these two methods and to CC e Cricoid Cartilage, T1 e First Tracheal ring.
evaluate the incidence of complications in intensive care

After skin disinfection, an operator determined the point of

puncture by palpation of standard anatomical landmarks.
Prior to PCT, he performed a US examination of the neck re-
Materials and methods gion with longitudinal sections to locate the cricoid cartilage,
the tracheal rings, and the puncture site (Fig. 1). Then he
This study was a prospective, single centre randomised con-
performed US transversal sections to identify arteries, veins,
trol trial (RCT) study of 74 consecutive patients. All patients
thyroid, trachea, and endotracheal tube and measure the
(or, for unconscious patients, the next of kin) gave their
thickness of the skin to the anterior tracheal wall (Fig. 2). After
written informed consent to participation. We enrolled all
having determined the puncture site the operator standing at
patients who were hospitalized in the ICU and HDU on whom
the patient's head withdrew the endotracheal tube's balloon
PCT was indicated. Exclusion criteria were as follows: age
from near the vocal cords under guidance from the US oper-
under 18 years, coagulation disorders (platelet count of below
ator. Next, a second operator performed the PCT by using the
80,000 mm3 and an international normalized ratio of at
single-stage dilator technique with US guidance. A puncture
least 1.5), and infection at the puncture site. Patients were
needle with a saline filled syringe was introduced perpendic-
randomly allocated into two groups of US guided PCT (USPCT)
ularly to the skin and advanced until the needle was seen to
and Bronchoscopic guided PCT (BPCT). The efficacy of USPCT
in comparison to BPCT was the primary outcome studies in
this RCT, while the secondary outcomes studies were the ease
of procedure and complications after both the procedures.
In both the groups PCT was performed after deep sedation
and analgesia by giving intermittent dose of ketofol and fen-
tanyl. Patients were ventilated under volume-targeted me-
chanical ventilation with a 100% fraction of inspired oxygen
(FiO2), and ventilatory parameters (tidal volume, respiratory
rate, and positive end-expiratory pressure) were kept con-
stant. Continuous monitoring (Three-lead electrocardiogram,
blood pressure, heart rate, and pulse oxygen saturation) was
The percutaneous tracheostomy technique was performed
by using the single-step, Griggs technique, The PCT set con-
sisted of a puncture needle, a guide wire, a small dilator, a
curved dilator forceps tracheostomy tube. The US machine
(Sonosite M turbo) was used with and probe of 6e12 MHz
frequency. The protocol required two operators: one dealt
with the airway while the other performed the US-guided PCT.
All operators had the same level of experience of PCT and Fig. 2 e US transverse view.
same level training in the use of US in anesthesia and critical V e Vein, TH e Thyroid, TL e Tracheal Lumen,
care medicine. TR e Tracheal ring.
160 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 1 5 8 e1 6 4

pass the anterior trachea wall during an aspiration of air. Then

the needle was angled caudally to prevent retrograde passage
of the guide wire. The needle was visualized in an ‘out-of-
plane’ mode (that is, the needle path was determined by the
presence of a distinct acoustic shadow ahead of the needle) on
a transversal section of the neck region (Fig. 3).The guide wire
was introduced, the needle was removed, and a small hori-
zontal incision was made at the point of puncture. The guide
wire was visualized as a hyperechoic signal on transversal and
longitudinal sections (Fig. 4). Throughout the procedure the
US probe was fixed with the customised ventilator circuit
holding arm (Fig. 5) and this was manipulated by the US
operator for transverse and longitudinal view. The sterility
was maintained with covering the USG probe and the Circuit
holding arm (Fig. 6) with a sterile cover. The small dilator was
then used to create the initial stoma followed by the single-
stage Griggs forceps dilator over the guide wire. The trache-
ostomy tube was guided over the guide-wire and passed
through the stoma. US provided the information on the cor- Fig. 4 e Guide Wire (Arrow showing the hyper echoic
rect positioning of the puncture site and the guide wire before signal). V e Vein, TR e Tracheal ring, TL e Tracheal Lumen.
the dilatation of the trachea and then placement of the tra-
cheostomy tube (Fig. 4). Endotracheal placement of the tube
was confirmed immediately using auscultation, verification of
appropriate breath delivery on the ventilator and the presence
of the sonographic “lung-sliding” bilaterally. The lung sliding
sign is the visible “sliding” of the visceral pleura on the parietal
pleura on ultrasound imaging through the intercostal space
along with a characteristic appearance on M-mode. Compli-
cations during the PCT procedure were monitored. An endo-
scopic check before decannulation of the patient (even in dead
patients) or before ICU discharge for non-decannulated pa-
tients was done.
In the Bronchoscopic PCT group video fiberscope was
introduced by the operator through the endotracheal tube
(ETT) and the ETT was withdrawn till the first and the second Fig. 5 e Customised arm holding US probe.
tracheal rings were visualised, after the anatomical land-
marks were delineated by the other operator performing the
PCT. A 2.5 cm small incision was made at the level of second

Fig. 3 e Needle Path. TR e Tracheal ring, TL e Tracheal

Lumen. Fig. 6 e Sterile cover for the customised arm.
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 1 5 8 e1 6 4 161

Fig. 7 e Bronchoscopic view of the guide wire.

tracheal cartilage. A saline filled finder needle was introduced ventilation of the patient in both US and Fiberscopic guided
into the trachea and visualised directly by the operator on the PCT, hemodynamic data before and after the completion of
screen attached with a camera to the bronchoscope. A 14 G PCT and complications. The ease of performance of both the
catheter over needle was introduced under bronchoscopic procedures was rated on a simple numerical scale; 1: easy 2: a
vision and guide-wire was passed through the catheter (Fig. 7). few difficulties 3: moderate difficulties 4: very difficult; and 5:
The small dilator was then used to create the initial stoma impossible.
followed by the single-stage Griggs forceps dilator over the Data were expressed as the median (25th to 75th percen-
guide wire. The tracheostomy tube was guided over the guide- tiles) or number (percentage). We compared the group of
wire and passed through the stoma. The placement of tra- USPCT with the group of BPCT patients. A non-parametric
cheostomy tube was confirmed by fibreoptic visualisation of ManneWhitney test was used for intergroup comparisons of
the bifurcation of trachea after fiberscope was passed through continuous variables. Categorical variables were compared by
the tracheostomy tube. using a chi-squared test (and a Yates correction if necessary)
Patient care began with PCT and ended with dec- or a Fisher exact test. A p value of not more than 0.05 was
annulation. Complications were defined as minor, interme- considered statistically significant.
diate, or major. Minor complications were defined as clinically
irrelevant and clearly did not harm the patient. Intermediate
complications were defined as potentially harmful for the Results
patient. Major complications required medical or surgical
intervention. The complications are listed and classified in Seventy four patients were prospectively enrolled between
Table 1.8 March 2012 and December 2013. Twenty-six patients were
The following data were collected: gender, age in years, obese -median BMI of 34 kg/m2 (32e38) e and five of the latter
height in meters, weight in kilograms, body mass index (BMI), were morbidly obese. The median ages were 58 years (50e66)
diagnosis on hospitalization, duration of mechanical venti- (mean 61 yrs, 1.2SD) in the (Bronchoscopic assisted Percuta-
lation prior to PCT (in days), indication for tracheostomy, the neous Tracheostomy (BPCT)) group and 62 years (56e64)
duration of the tracheostomy defined by the time (in mi- (mean 58 yrs, 1.6SD) in the Ultrasound assisted percutaneous
nutes) between the puncture of the trachea and the tracheostomy (USPCT) group (P ¼ 0.62) (Table 2). Of the 74

Table 1 e Classification of complication.

Minor Major Severe
Bleeding <5 ml Bleeding <50 ml Bleeding requiring compression transfusion
Hypoxemia (Spo2 < 90 for 5 mins) Posterior tracheal wall injury (no req of surgery) Esophageal injury
Difficult puncture Subglottic stenosis Post tracheal wall injury (req surgery)
Multiple puncture (>3) Granuloma Pneumothorax
Tracheal tube cuff puncture Periosteal infection (not req antibiotic) Periosteal infection (req antibiotic)
Atelectasis Loss of airway
Tracheal ring fracture Surgical conversion
Cardiac arrest/death
162 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 1 5 8 e1 6 4

Table 2 e Profile of overall study population.

Nomenclature Total PTS Percent BPCT Percent UPCT Percent p value
PCT 74 36 38
Age 64 58 62
Male 42 22 20
BMI 25 24 26
Diagnosis on ADMN
ARDS 21 28.38 11 30.55 10 26.3 0.28
COPD 27 36.48 12 33.33 15 39.47 0.69
Neuro prob 18 24.32 10 27.77 8 21.05 0.34
Polytrauma 6 8.11 4 11.11 2 5.26 0.35
Cardiac Sx 2 2.70 2 5.55 0 0 e
Visceral (GI) Sx 6 8.11 4 11.11 2 5.26 0.42
MVa before tarcheostomty 6 8.12 5 13.88 7 18.42 0.24
Time to decannulate 18 24.32 16 44.44 21 55.26 0.66
Short neck 12 16.22 8 22.22 6 15.79 0.54
Tracheal deviation 14 18.92 5 22.22 9 23.68 0.65
Cricoid manu distance 6.2 8.38 7.1 13.89 5.8 15.27 0.42
Percut time 14 18.92 16 44.44 12 31.58 0.05
Numerical scale
Easy 56 75.68 26 72.22 30 78.95
MOD difficult 16 21.62 8 22.22 8 21.05
V difficult 2 2.70 2 5.55 0 0
Impossible 0 0 0 0 0 0
Complications 42 27 75 2 5.26
Minor complications
Hypotension 6 8.12 1 2.78 2 5.26
Spo2 <90% 6 8.12 4 11.1 0 0 0.05
Tracheal cuff puncture 8 10.81 8 22.22 0 0 0.05
Bleed < 5 ML 12 16.21 8 22.22 0 0 0.05
Multiple puncture 4 5.40 4 11.11 0 0 0.11
Intermediate granuloma 0 0 0 0 0 0
Major complications
Bleed < 50 ML 4 5.40 4 11.11 0 0 0.05
Infection 2 2.70 2 5.56 0 0
MV e Mechanical ventilatory days before the procedure (percutaneous tracheostomy).

patients, 60 patients (81%) had been hospitalized for a medical two patients (2.70%). The median times to decannulation was
problem (respiratory failure in chronic obstructive pulmonary 16 days (13e28) (mean 21.6 min 1.4SD) in BPCT group and 21
disease, stroke, seizures, ARDS) and 14 (%) had undergone days (16e29) (mean 24.6 1.8SD) in USPCT group (P ¼ 0.66). It
cardiac, vascular, or digestive surgery or severe trauma. The was possible to carry out all PCTs with US and bronchoscopic
most frequent indication for tracheotomy was difficult guidance. No surgical conversions occurred.
weaning from predictable, prolonged mechanical ventilation In terms of complications, we observed 8 tracheal cuff
(due to COPD in 39% of cases). Indications for PCT in both the punctures (22.2%) in the BPCT group and nil punctures in
groups were comparable since they were allotted randomly. USPCT group which was statistically significant (p < 0.05). The
Table 2 presents profile of the study population. number of multiple puncture were also more in BPCT (4)
Twelve patients (16.2%) had a short neck, and the median against UPSCT (0) (11.11%e0) although was not statistically
cricoid-manubrium distance was 6.2 cm (5.5e7.6) (mean6.4 cm, significant. Intra-procedural complications included desatu-
1.4SD). The prevalence of a short neck was higher in the BPCT ration for less than 5 min in four patients (11.11%) in the BPCT
group than in the USPCT (16.2% and 15.78% respectively; group in comparison to USPCT which had nil incidence of
P ¼ 0.54). hypoxia (p < 0.05). There was 12 cases (32.22%) of minor
The median total time for performing the PCT was 14 min (<5 ml) bleeding and four cases (11.11%) of major bleed
(10e23) (mean 19.4 min, 1.6SD). For BPCT group it was 18 min (<50 ml) in the BPCT group which was statistically significant
(12e21.5) (mean 16.3 min 1.6SD) while for USPCT it was 12 min in comparison to the USPCT (P < 0.05). None of the patients
(9e14) (mean 10.2 min 1.8SD) which was statistically signifi- had severe bleeding. One patient (2.27%) of BPCT group had an
cant. Five cases of the BPCT group had tracheal deviation episode of hypotension for less than 5 min in comparison to
(22.2%) while this was encountered in 9 patients of USPCT two patients in USPCT (5.26%). Post-procedural complications
group (23.68%). Identification of the anatomical structures and included skin infection among two patients (2.70%) among the
the PCT guidance were considered to be easy in 56 patients BPCT group that resolved easily with local care and intrave-
(75.67%), moderately difficult in 16 patients (21.6%), difficult in nous antibiotics.
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 1 5 8 e1 6 4 163

occurrence of complications was linked to the difficulty in

Discussion identifying anatomical features.15 In a study by Byhahn and
colleagues6 bronchoscopy-guided PCT was five times more
Our results demonstrate that PCT can be performed under likely to result in serious adverse events in obese patients than
real-time US guidance as efficacious if not with better results in non obese patients. Ours was the first study to compare the
in comparison bronchoscopic guided PCT and with a short incidence of these complication with real time USPCT and
completion time. Several studies have emphasized the value BPCT in randomly allocated patients, although Rajajee et al in
of pre-PCT US examination of the neck region to reduce the a feasibility study of 13 patients of postulated that less com-
incidence of complications.9 Recently, Rajajee et al demon- plications will happen if real time USG is used for PCT.10
strated the feasibility of US guidance during the imple- The advantage of USPCT is its ability to avoid vascular
mentation of PCT in a population of neuro-intensive care structures anterior to the trachea. Prior studies have
patients.10 USPCT has many potential advantages over other demonstrated a potential role for pre-procedure ultrasound
techniques of PCT. The first is the ability to consistently place imaging in transverse section to identify vascular structures
the tracheostomy tube below the first tracheal ring. Placement and reducing the risk of bleeding.10,13,14 In one study,
of the tracheal tube above the first tracheal ring may increase bleeding from injury to vascular structures which would have
the risk of late sub-glottic cicatrization and stenosis.7,9,10 In likely been identified had ultrasound been used was consid-
one study of patients who underwent autopsy following PCT, ered significant.7,15 Pre-procedure ultrasound resulted in a
5 of 15 patients had the tracheal tube placed above the first change in the planned site of tracheal puncture in 24% of
tracheal ring when the tube was placed blindly vs zero of 11 patients in another study.14 These studies did not use real-
patients when PT was performed with ultrasound guidance.11 time guidance for performance of PCT. In our study, none
Real-time imaging of the needle path allows visual confir- of the patients who underwent USPCT had bleeding since the
mation that the anterior wall has been passed, at which point vascular structures were clearly delineated. In BPCT group 12
the needle is advanced no further and posterior wall injury is patients had minor to moderate amount of bleeding. The use
avoided. of real-time imaging may be preferable for avoiding vascular
In the presence of obesity, sub-optimal palpable neck structures compared to pre-procedure imaging alone, since
anatomy or cervical spine precautions did not appear to be a avoidance of a vascular structure such as an inferior thyroid
barrier to the performance of US-PT. None of the patients had vein cannot be taken for granted without actual visualization
a prior tracheostomy done. Prior studies have shown that PCT of the needle path.
should be automatically contraindicated in these groups of The ability to perform USPCT without bronchoscopy or
patients.5,9 Many of the patients in our series had one of these direct laryngoscopy to safely retract the oro-tracheal tube to a
factors: obesity in 15 patients (including one patient with BMI position high enough to permit tracheal puncture while
55.9 kg/m2) and cervical spine precautions in 8 patients. Nine avoiding accidental extubation is debatable. One study
of the obese patients who underwent USPCT in comparison to described using Doppler ultrasound over the trachea to
6 BPCT had no incidence of any complication while all the six determine the correct position of the orotracheal tube.13
undergoing BPCT had complications (4 tracheal cuff puncture, Laryngeal mask airways have been used successfully instead
3 had hypoxia while 2 had moderate bleeding). We believe that of oro-tracheal tubes during PCT,7,13,16 although the relative
our technique of real-time US guidance will further enhance safety of this technique is debatable. In our study we solely
the safety and ease of performance of PT in these sub-groups used US guidance to identify the tracheal cuff and pull it up
as these factors appeared to present no increased difficulty for enough to facilitate a tracheal puncture.
the performance of ultrasound. All of the practitioners in our study had been trained by a
The majority of complications were minor and moderate radiologist on the anatomy of neck as revealed by US. Even so,
ones (hypotension, desaturation, minor bleeding, and punc- the cervical anatomy was identified with great difficulty in
ture of the tracheal tube cuff). We did not observe any life- eight patients (23.4%) but did not prevent PCT. There were
threatening complications. By using standardized definitions several reasons for this great difficulty. Short, thick necks
to evaluate the incidence and severity of complications limited our ability to carry out a US examination. The presence
(particularly in obese patients), we observed a lower incidence of a large, hypoechoic, anterior venous maze hindered guid-
of complications than reported in the literature.10,12 Among ance of the needle. Another difficulty was in identifying the
the complications incidence of hypoxia, minor and moderate balloon of the endotracheal tube with sonography; although
bleed and tracheal cuff puncture were more in the BPCT group we did not had a single case of tracheal cuff perforation. Two
which was statistically significant. The incidences of hypoxia other studies reported a rate of tracheal tube cuff puncture of
in BPCT group more than USPCT may be due to the fact that 13%e17% for bronchoscopy-guided PCT.7,8,16 Even though US
there is a breach of continuity of the close airway by the way cannot correctly identify the tracheal tube.
of disconnection/opening of definitive airway device for Our goals were to evaluate the efficacy of USPCT and to
insertion of bronchoscope. The use of US guidance may ac- describe the implementation difficulty and occurrence of
count for these results since this modality is probably more complications in a critically ill population rather than
informative than bronchoscopy in terms of identification of demonstrate its superiority of BPPCT. Larger, randomized
the cervical anatomy, vascular anatomy and puncture studies are required to better define the relative advantages of
site.13,14 Walz et al highlighted the discrepancy between the this technique, appropriate candidates, safety and long term
palpated landmarks and the actual level of puncture during complications of US-PCT. The extrapolation of our results to
fiber-optic monitoring.11 Massick et al found that the other teams (with little or no training in US or cervical
164 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 1 5 8 e1 6 4

anatomy) might be a concern. A learning curve might well be 4. Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational
required before the technique can be incorporated into tracheostomy versus surgical tracheostomy in critically ill
routine use. patients: a systemic review and meta-analysis. Crit Care.
5. Kost KM. Endoscopic percutaneous dilatational tracheotomy:
a prospective evaluation of 500 consecutive cases.
Conclusions Laryngoscope. 2005;115:1e30.
6. Byhahn C, Lischke V, Meininger D, Halbig S, Westphal K. Peri-
US-guided PCT can be performed in safely in critically ill pa- operative complications during percutaneous tracheostomy
tients, and the incidence of complications is low. Use of US in obese patients. Anaesthesia. 2005;60:12e15.
7. Aldawood AS, Arabi YM, Haddad S. Safety of percutaneous
provides a better understanding of the anatomy of the neck,
tracheostomy in obese critically ill patients: a prospective
prevents vascular puncture, and helps guide the tracheos-
cohort study. Anaesth Intensive Care. 2008;36:69e73.
tomy procedure. 8. Guinot Pierre-Gre goire, Zogheib Elie, Petiot Sandra, et al.
Ultrasound-guided percutaneous tracheostomy in critically ill
obese patients. Crit Care. 2012;16:R40.
Key messages
9. Sustic A, Zupan Z, Antoncic I. Ultrasound-guided
 Ultrasound-guided percutaneous tracheostomy is percutaneous dilatational tracheostomy with laryngeal mask
feasible in place of BPCT and has a low complication airway control in a morbidly obese patient. J Clin Anesth.
rate. 2004;16:121e123.
10. Rajajee V, Fletcher JJ, Rochlen LR, Jacobs TL. Real-time
 Ultrasound provides a better understanding of the
ultrasound-guided percutaneous dilatational tracheostomy: a
anatomy of the neck, prevents vascular puncture, and feasibility study. Crit Care. 2011;15:R67.
helps guide the tracheostomy procedure. 11. Walz MK, Schmidt U. Tracheal lesion caused by percutaneous
dilatational tracheostomy: a clinico-pathological study.
Intensive Care Med. 1999;25:102e105.
12. Flint AC, Midde R, Rao VA, Lasman TE, Ho PT. Bedside
ultrasound screening for pretracheal vascular structures may
Conflicts of interest minimize the risks of percutaneous dilatational
tracheostomy. Neurocrit Care. 2009;11:372e376.
All authors have none to declare. 13. Sustic A, Kovac D, Zgaljardic Z, Zupan Z, Krstulovic B.
Ultrasound-guided percutaneous dilatational tracheostomy:
a safe method to avoid cranial misplacement of the
references tracheostomy tube. Intensive Care Med. 2000;26:1379e1381.
14. Singh M, Chin KJ, Chan VW, Wong DT, Prasad GA, Yu E. Use of
sonography for airway assessment: an observational study.
1. Sustic A. Role of ultrasound in the airway management of J Ultrasound Med. 2010;29:79e85.
critically ill patients. Crit Care Med. 2007;35:S173eS177. 15. Massick DD, Powell DM, Price PD, et al. Quantification of the
2. Griffiths J, Barber VS, Morgan L, Young JD. Systematic review learning curve for percutaneous dilatational tracheotomy.
and meta-analysis of studies of the timing of tracheostomy in Laryngoscope. 2000;110:222e228.
adult patients undergoing artificial ventilation. BMJ. 16. Romero CM, Cornejo RA, Ruiz MH, et al. Fiberoptic
2005;330:1243. bronchoscopy-assisted percutaneous tracheostomy is safe in
3. Blot F, Melot C. Indications, timing, and techniques of obese critically ill patients: a prospective and comparative
tracheostomy in 152 French ICUs. Chest. 2005;127:1347e1352. study. J Crit Care. 2009;24:494e500.