Tracheotomy: timing and techniques.

PURPOSE OF REVIEW: Until the past 40 years, the timing of tracheotomy was of little concern. It was an emergency procedure developed for the relief of airway obstruction. Following the development of positive pressure ventilation, tracheotomy became an elective procedure. Today, the optimal time for tracheotomy is a subject of dispute and continued investigation. As this operation has become one of the most commonly performed procedures in the intensive care unit, nonoperative dilational methods have gained acceptability. The purpose of this review is to analyze the recent literature and draw insight into the timing and technique of the current state of tracheotomy. RECENT
FINDINGS: Individualized assessment of patients should guide the timing of tracheotomy, with a preference toward early tracheotomy. Percutaneous dilational tracheotomy (PDT) can be performed with equivalent safety to open tracheotomy. Bedside open tracheotomy negates the cost-saving benefits of PDT. Endoscopic guidance in PDT decreases complications with needle placement and posterior tracheal wall injury. Major complications of PDT usually are associated with displacement of the tracheotomy tube.
SUMMARY: Tracheotomy indications have remained unchanged, but the timing of the procedure has advanced to individualized assessment with a predilection for earlier tracheotomy. The traditional operative technique is a much safer procedure today. Percutaneous dilational tracheotomy has become an acceptable alternative with proper patient selection. A multidisciplinary team with a surgeon provides the best care for the patient undergoing percutaneous tracheotomy.