Percutaneous Tracheotomy 

Updated: Aug 15, 2022
Author: Roy R Danks, DO, FACOS; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Practice Essentials

Tracheotomy, as a means of airway access, is one of the oldest surgical procedures documented, dating back approximately 4000 years. However, it wasn’t until the early 20th century, when Chevalier Jackson introduced clear guidelines, that tracheotomy was deemed a safe and viable procedure. With advances in technology and increasing interest in minimally invasive procedures, variations of the standard open tracheotomy have evolved over the last several decades.

Since Ciaglia et al introduced the percutaneous dilatational tracheotomy (PDT), in 1985, PCT has become increasingly popular and has gained widespread acceptance in many intensive care units (ICUs) as a viable alternative approach.[1, 2]  In some institutions, percutaneous tracheotomy (PCT) has become the procedure of choice.

PCT should generally be considered an elective procedure. Although emergent application of PCT has been reported in the literature, one might be better off considering a cricothyroidotomy, given its relative ease of performance and the limited need for specialized equipment to complete the task. The overall goal in such patient care, regardless of how it is achieved, is to provide a long-term, secure airway and to take into account airway protection, maintenance, and pulmonary toilet.

Providers wishing to perform PCT must have proper training; this includes training in (and comfort with) the control of unexpected bleeding, alternatives to the planned procedure (should complications arise), relevant anatomy, and follow-up care of the tracheotomy. The provider must know when to downsize and decannulate and how to diagnose and manage complications such as tracheal stenosis, innominate artery stenosis, or tracheoinnominate fistula formation.

Most PCTs are performed rather quickly and with few immediate complications. However, as with any invasive procedure, substantial risks are involved; these include bleeding, infection, injury to nearby aerodigestive structures, and catastrophic airway loss leading to hypoxia, anoxia, or even death. However, in well-trained hands, the procedure can be safely carried out at the bedside in the intensive care setting or in the operating room. Variations in technique stem from surgeon preference regarding the available pre-packaged supplies, as well as individual experience.

Multiple studies that provide clear support for the less invasive percutaneous methods have been published. The most consistently reported benefits include decreased rate of surgical site infection, reduced operative time, and lower procedure cost.[3]  Although it is beyond the scope of this article, the actual timing of the procedure depends on numerous factors. Ultimately, the physician providing the long-term ventilator care will determine the proper time to undertake this advanced airway procedure.  

History of the Procedure

The percutaneous airway techniques that were developed not long after Seldinger described needle replacement over a guidewire for arterial catheterization (1953) have evolved to the present-day versions. In 1955, Shelden et al reported the first attempt to perform PCT.[4] They gained airway access with a slotted needle that then was used to guide a cutting trocar into the trachea. Unfortunately, the method caused multiple complications, and fatalities were reported secondary to the trocar's laceration of vital structures adjacent to the airway.

Percutaneous airway access methods have subsequently improved, and various techniques and refinements have been reported.

Although a tracheotomy technique based on a single tapered dilator with a recessed cutting blade was reported as early as 1969,[1]  several variations of PCT appeared in the years that followed.[5, 6, 7]

Then, in 2000, Byhahn et al introduced the Ciaglia Blue Rhino technique, which is a modified version of the Ciaglia technique.[8]  When this procedure is used, dilation of the stoma is formed in a single step, utilizing a curved, tapered dilator coated with hydrophilic material—the Blue Rhino. This method reduces the risks of posterior tracheal wall injury and intraoperative bleeding, as well as the adverse effects on oxygenation caused by repeated airway obstruction during serial dilation. 

Some of the most recent techniques were developed in the mid-2000s and include the PercuTwist technique[9] and a balloon dilation technique.[3]  Among the various PDT techniques developed, the Ciaglia Blue Rhino method is probably the most commonly used worldwide.

Indications

In the ICU, the most common indication for tracheotomy is the need for prolonged mechanical ventilation, occurring in 5-10% of the ICU population.[3] This need may arise from pneumonia refractory to treatment, severe chronic obstructive pulmonary disease, acute respiratory distress syndrome, severe brain injury, smoke inhalation injury, or multiple organ system dysfunction. The Council on Critical Care of the American College of Chest Physicians recommends tracheotomy in patients who are expected to require mechanical ventilation for longer than 7 days.

Indications for PCT are the same as those for standard open tracheotomy. Please refer to the Medscape Drugs & Diseases article Tracheostomy to review the main advantages of tracheotomy over prolonged translaryngeal intubation.

Airway obstruction may be due to the following:

  • Inflammatory disease
  • Congenital anomaly (eg, laryngeal hypoplasia, vascular web)
  • Foreign body that cannot be dislodged with Heimlich and basic cardiac life support (BCLS) maneuvers
  • Supraglottic or glottic pathologic condition (eg, neoplasm, bilateral vocal cord paralysis)
  • Laryngeal trauma or stenosis
  • Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the midface and mandible)
  • Edema (eg, trauma, burns, infection, anaphylaxis)

Indications for PCT also include the following:

  • Need for prolonged mechanical ventilation in patients experiencing respiratory failure

  • Need for improved pulmonary toilet

    • Inadequate cough due to chronic pain or weakness

    • Aspiration and the inability to handle secretions (The cuffed tube allows the trachea to be sealed off from the esophagus and its refluxing contents. However, some argue that secretions can leak around the cuffed tube and reach the lower airway.)

  • Prophylaxis (as in preparation for extensive head and neck procedures and the convalescent period)

  • Severe sleep apnea not amenable to continuous positive airway pressure (CPAP) devices or other, less invasive surgery

Special consideration is required for creation of a tracheotomy in patients with burn injuries. Such individuals may require surgical control of the airway immediately after injury and on a long-term basis as the injuries heal. In the acute setting, neck burns often accompany facial burns, and both facial and neck burns are commonly associated with inhalation injury. In patients with burns who arrive intubated, but with risk of loss of airway due to ensuing facial edema, tracheotomy may be indicated.

Although there is no strict contraindication for percutaneous (dilatational) tracheotomy in patients with burn injuries, the physician is cautioned about performing it in these individuals. The edema accompanying deep burns of the anterior neck can result in loss of tissue planes and increase the difficulty of the operation. Added to this is the risk of loss of an orotracheal or nasotracheal tube already in place. Because the risk of airway loss is significant, extreme caution is advised. As with other patients with complicated injuries and those at high risk for poor outcomes, a formal tracheotomy performed in the operating room may be a better option.

Contraindications

 

Determination of absolute and relative contraindications remains a matter of debate. In most published articles, cervical injury, pediatric age, coagulopathy, and a need for an emergency airway are considered absolute contraindications, whereas a short, fat neck and obesity are relative contraindications. However, there have been several reports suggesting that performance of PCT in patients with the previously described contraindications can be safe and feasible.[10, 11, 12, 13, 14, 15, 16]

In a retrospective study, Blankenship et al suggested that PCT may be performed safely in a patient with morbid obesity as long as anterior neck landmarks can be palpated and in a patient with coagulopathy who has a platelet count as low as 17,000 and an international normalized ratio of 1.7.[10] Tabaee et al demonstrated the safety of PDT in patients with short neck lengths in their prospective, randomized study.[15] PCT was found to be safe and feasible even in emergency trauma cases in a case series study by Ben-Nun et al,[12] while Gravvanis et al[13] showed, in their retrospective study, that PCT can be safely and more rapidly performed in patients with burns and associated inhalation injury at the bedside. PCT was also found to be safe and feasible in patients with cervical spine fractures in a case series by Ben-Nun and colleagues.[14]

Kornblith et al reviewed data for 1000 patients who underwent bedside PCT over 10 years and found it to be a safe procedure with minimal complications, even for high-risk patients.[17]

Absolute contraindications are as follows:

  • Patient age younger than 8 years

  • The necessity of emergency airway access because of acute airway compromise

  • Gross distortion of the neck anatomy due to the following:

    • Hematoma

    • Tumor

    • Thyromegaly (second or third degree)

    • High innominate artery

Relative contraindications are as follows:

  • Patient obesity with a short neck that obscures neck landmarks

  • Medically uncorrectable bleeding diatheses

    • Prothrombin time or activated partial thromboplastin time more than 1.5 times the reference range

    • Platelet count less than 50,000/µL

  • Bleeding time longer than 10 minutes

  • Need for positive end-expiratory pressure (PEEP) of more than 20 cm of water

  • Evidence of infection in the soft tissues of the neck at the prospective surgical site

PCT is no longer considered absolutely contraindicated in patients with necks that are difficult to extend (eg, due to trauma or previous cervical fixation) or previous PCT. In fact, the previous site of PCT provides a reliable access site, and wound healing in the scar has not proven to be an issue.[3]  Clinical judgment is used on a case-by-case basis to determine safety and feasibility.

Relevant Anatomy

A plexus of veins is found in the neck, including veins that drain the thyroid, the inferior laryngeal vein, and the anterior jugular vein. Although these veins are not visualized during PDT, it is necessary to know their approximate location and the inherent risk of bleeding should one of these vessels be injured. Given that the incision for PDT is small, there will be limitations to accessing the cut ends of bleeding vessels. Absorbable suture material should be available for vessel ligation.

Preoperative Workup

Laboratory Studies

These include the following:

  • Complete blood count: Platelet count must be more than 50,000/µL

  • Coagulation profile: Prothrombin time or activated partial thromboplastin time must be less than 1.5 times the reference range[18, 19]

  • Bleeding time: Check if blood urea nitrogen is more than 40 mg/dL or if the creatinine level is above 4 mg/dL; bleeding time must be less than 10 minutes

Imaging

A standard chest radiograph can provide information regarding the tracheal air column. Anteroposterior filtered tracheal views and lateral soft tissue views of the neck provide information regarding the glottic and subglottic air columns.

 

Treatment

Approach Considerations

It is worth reiterating that percutaneous tracheotomy (PCT) is ideally performed under controlled circumstances, whether in the ICU or the operating room. All necessary equipment should be present, and adequate lighting is mandatory. A team knowledgeable in the procedure should assemble and review the operative approach and plan. Backup emergency contingency plans should be reviewed in the event of a catastrophic loss of airway or other emergent or urgent complications.

Sound knowledge of the procedure and the available tools within the kit to be used is critical.

Surgical Therapy

Numerous investigative reports show that all techniques for PCT (eg, guidewire dilating forceps [GWDF], Rapitrach, percutaneous dilatational tracheotomy [PDT]) have similar success rates. All techniques are based on the use of a needle guidewire to gain airway access. However, each method requires unique equipment and follows a different intraoperative procedural sequence. For example, all techniques that are conducted by serial dilatations of the stoma with commercial dilatators could be classified under PDT.

With regard to the operating physician, proper training will reduce the chances of a catastrophic event that can cause harm, or even death, in an otherwise stable patient.

Patient positioning

The ideal positioning of the patient includes some neck extension, allowing the anterior structures of the neck to be placed as far forward as possible for improved palpation of relevant structures.  This can be done by placing a shoulder roll behind, in the midline, or transversely across the upper back. Obviously, in a patient with a known or suspected cervical or thoracic spinal injury, inline stabilization disallows neck extension. If the patient has undergone cervical or thoracic spine fixation, it is advisable to consult with the operating (spinal) surgeon regarding the positioning of the patient.

Preoperative Details

Equipment

See the list below:

  • PDT kit (Cook Critical Care Inc, Bloomington, IN): 22-gauge needle and syringe; 11-F short punch dilator; 1.32-mm guidewire; 8-F guiding catheter; 18-F, 21-F, 24-F, 28-F, 32-F, 36-F, and 38-F dilators; Shiley size 8 double-cannula tracheotomy tube; fiberoptic bronchoscope

  • GWDF kit (Sims Portex): 14-gauge needle and syringe, guidewire (J-tipped Seldinger wire type), scalpel, Howard-Kelly forceps modified to produce a pair of GWDF (seen in the image below), Shiley size 8 double-cannula tracheotomy tube with curved obturator, fiberoptic bronchoscope

    Guidewire dilator forceps (GWDF). Guidewire dilator forceps (GWDF).
  • Rapitrach kit (Fresenius, Runcorn, Cheshire, UK): 12-gauge needle and syringe, short guidewire, scalpel, Rapitrach PCT dilator (seen in the image below), standard Portex 8-mm tracheotomy tube with curved obturator, fiberoptic bronchoscope

    Rapitrach dilating forceps. Rapitrach dilating forceps.
  • Ciaglia Blue Rhino kit (Cook Critical Care Inc, Bloomington, IN): 14-gauge catheter introducer needle and syringe, guidewire (J-tipped Seldinger wire type), guiding catheter, introducer dilator, loading dilators, single tapering Blue Rhino dilator, Shiley size 8 double-cannula tracheotomy tube with curved obturator; fiberoptic bronchoscope

Anesthesia

See the list below:

  • Intravenous sedation with the type and dosage of medications dictated by the clinical needs of the patient.

  • Administer 100% oxygen to the patient throughout the procedure.

  • Hyperextend the patient's neck if no contraindications exist. Before preparation of the surgical area begins, withdrawal of the endotracheal tube under direct vision of bronchoscope is recommended to place the balloon just under the vocal cords. The respiratory therapist then protects the tube against any further movement during the procedure.

  • Infiltrate the incision site with a solution of 1-2 2% lidocaine with 1:100,000 epinephrine.

Intraoperative Details

Percutaneous dilatational tracheotomy (PDT) technique

The neck is cleansed with an antiseptic solution and properly draped. The cricoid cartilage is identified, and the skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1.5- to 2-cm transverse or vertical skin incision is made at the level of the first and second tracheal rings. Then, blunt dissection of the midline is performed using the tips of a curved hemostat. A 22-gauge needle is inserted between the first and second or the second and third tracheal rings. This is represented in the image below. Note that the angle of entry is slightly caudad. This helps to ensure that the needle tip travels away from the endotracheal tube tip and balloon. It is ideal to have another provider performing flexible bronchoscopy so that midline needle placement can be seen. This should also help to ensure that the needle does not inadvertently enter the eyelet of the distal endotracheal tube.

When air is aspirated into the syringe, the guidewire is introduced. After the guidewire is protected, the dilators are introduced. All dilators are inserted in a sequential manner from small to large diameter. The tracheostomy tube is then introduced along the dilator and guidewire. The guidewire and dilator are removed, the cuff of the tracheostomy tube is inflated, and the breathing circuit is connected. The endotracheal tube is removed. The procedure is represented in the images below.

Percutaneous dilatational tracheotomy (PDT techniq Percutaneous dilatational tracheotomy (PDT technique). After removing the needle and reaspirating to confirm catheter location in the airway, the guidewire is placed.
Percutaneous dilatational tracheotomy (PDT techniq Percutaneous dilatational tracheotomy (PDT technique). Serial dilations are performed over the guidewire.
Percutaneous dilatational tracheotomy (PDT techniq Percutaneous dilatational tracheotomy (PDT technique). A tracheostomy tube is inserted in the dilated passageway using a dilator as obturator over the guidewire.

A study by Vallejo-Díez et al indicated that in performing a PCT in patients severely infected with SARS-CoV-2 (the virus that causes coronavirus disease 2019 [COVID-19]), keeping the patient under apnea during the procedure is a safe approach that reduces the risk of virus exposure. Out of 35 PDTs performed, none of the involved healthcare providers subsequently had symptoms or a diagnosis of COVID-19. Moreover, although about one third of patients died from SARS-CoV-2–related respiratory complications, no mortality was associated with PDT. The procedure was performed under fibroscopic control via an endotracheal tube.[20]

Guidewire dilating forceps technique

The neck is cleansed with an antiseptic solution and properly draped. The neck is palpated, and the cricoid cartilage is identified. The skin below this level is anesthetized with 1% lidocaine with 1:100,000 epinephrine solution. A 1.5- to 2-cm midline transverse cutaneous incision is made at this level. A 14-gauge intravenous needle with a syringe is inserted in the midline of the incision. The needle is directed to pass between the first and second or the second and third tracheal rings. As soon as air begins to bubble into the syringe, the outer plastic cannula is advanced into the lumen of the trachea and the inner needle is removed. A J-tipped Seldinger wire is introduced into the trachea, and the plastic cannula is removed. The tip of the Seldinger wire is passed through the closed GWDF.

The forceps are advanced through the soft tissues of the neck until resistance is felt. The GWDF are opened to dilate the soft tissues anterior to the trachea. The forceps are then closed and reinserted over the wire into the trachea. A slight loss of resistance occurs as the tracheal membrane is pierced. To prepare the stoma of the tracheotomy, the GWDF are opened to the same diameter as the skin incision. A tracheostomy tube with obturator is inserted over the guidewire and advanced into the trachea. The obturator and guidewire are removed, the cuff of the tracheostomy tube is inflated, and the appropriate breathing circuit is connected. The endotracheal tube is removed. The procedure is represented in the images below.

Guidewire dilating forceps (GWDF) technique. The g Guidewire dilating forceps (GWDF) technique. The guidewire dilator forceps are advanced along the Seldinger wire into the long axis of the trachea.
Guidewire dilating forceps (GWDF) technique. The g Guidewire dilating forceps (GWDF) technique. The guidewire dilator forceps enlarge the hole between tracheal rings.

Rapitrach technique

The neck is cleansed with an antiseptic solution and properly draped. The skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1.5- to 2-cm skin incision is created at the level of the first and second tracheal rings. Subcutaneous layers are then bluntly dissected with a pair of forceps. Blunt dissection is continued until the tracheal rings can be palpated with a finger. A 12-gauge needle is inserted into the trachea between the first and second or second and third rings. A short, flexible guidewire is inserted into the trachea, and the needle is removed.

The Rapitrach dilator is introduced into the trachea over the guidewire. The dilator is opened when its tip lies in the trachea. A tracheostomy tube with obturator is inserted through the dilator jaws to the trachea. The dilator and guidewire are removed, the cuff of the tracheostomy tube is inflated, and the breathing circuit is connected. The endotracheal tube is removed.

Bronchoscopic guidance of the insertion of the gauge needle and guidewire is optional but strongly recommended, especially for less-experienced operators.[21] A large number of paratracheal cannula insertions and pneumothoraces can be avoided if endoscopic monitoring is employed. Bronchoscopic monitoring also allows patients with short, fat necks to undergo PCT. However, bronchoscopic guidance during PCT appears to be the most important factor responsible for the hypercarbia that develops during the procedure. Therefore, bronchoscopic guidance should be limited to initial dilatation steps only.

Ciaglia Blue Rhino technique

The neck is cleansed with an antiseptic solution and properly draped. The cricoid cartilage is identified, and the skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1- to 1.5-cm transverse skin incision is made at the level of the first and second tracheal rings. Then, blunt dissection of the midline is performed. A 14-gauge angiocatheter is inserted between the first and second or the second and third tracheal rings.

When air is aspirated into the syringe, the guidewire is introduced. After the guidewire is protected, the Blue Rhino single tapering dilator is introduced over the guidewire until the stoma is dilated to an adequate diameter (36-F to 38-F). Once dilation is achieved, the tracheostomy cannula is assembled with one of the three intermediate dilators. Once assembled, it is advanced over the guidewire until the cannula is in place within the tracheal lumen. The intermediate dilator and guidewire are removed, the cuff of the tracheostomy tube is inflated, and the breathing circuit is connected.

Fiberoptic Bronchoscopy

The authors strongly suggest the use of fiberoptic bronchoscopy when performing PCT.  The advantages of bronchoscopic monitoring during the procedure include excellent visualization of the intratracheal area, lessening the risk of a "sidewall" injury, assessment of the trachea for undiagnosed intraluminal lesions that may impede proper placement of the tracheostomy tube, and preoperative and postoperative bronchoscopic lavage or toilet for removal of excess secretions.

The use of bronchoscopy adds to the number of personnel required. However, this is an insignificant cost, given the speed with which the procedure is normally performed and the added set of hands available in the event of a catastrophic airway loss.

A well-known—and expensive—byproduct of fiberoptic bronchoscopy–assisted PDT is the accidental puncture of the bronchoscope. This will damage fiberoptics and result in the need for expensive repairs. Shen et al reported the successful use of an adjunct to prevent this. When a rigid plastic cover with a side port, placed over a laser pointer (sheathed in a sterile glove), is used, the proper location of the needle's entry can be ensured. The side port sits at an angle to the light, while the needle is advanced. After using this novel device, Shen and colleagues reported no bronchoscope damage in 100 PDTs they performed.[22]

Intraoperative and Postoperative Considerations

Intraoperative considerations

If electrocautery is to be used at any point in the procedure, the oxygen level must be turned down in the ventilator circuit.  It is absolutely critical for the operating surgeon and the person managing the airway to communicate with each other regarding the concomitant use of an ignition source and an oxidizer (oxygen). In such circumstances, it is wise to keep a basin of water on the field so that if a fire occurs, it can be quickly extinguished.

Postoperative considerations

Following successful PCT:

  • Air entry into the lungs is checked by chest auscultation and respiratory plethysmography

  • Excess secretions or blood should be suctioned to prevent a drop in oxygen saturation and to provide good bronchopulmonary hygiene

  • Antiseptic wound care must be provided every day; a tracheostomy tube with an inner cannula facilitates care and hygiene and ensures added safety (due to easy removal) if obstruction from secretions occurs

  • In the event of accidental decannulation within 5-7 days of the procedure, the patient may need to be reintubated orally if the tracheostomy tube cannot be immediately reinserted because the tracheostomy tract is still relatively immature

Follow-up

Patient care

This includes the following:

  • Monitor the patient to prevent dislodgment of the tracheostomy tube

  • Deliver oxygen and/or mechanical ventilation as needed to maintain the patient's oxygen saturation and maintain appropriate ventilation

  • If using a cuffed tracheostomy tube, monitor cuff pressure carefully because prolonged inflation and/or overinflation can lead to tracheal mucosal injury

  • Clean the inner cannula to clear secretions at least once every 8 hours

  • Suction the trachea as needed

  • If long-term tracheotomy is needed, arrange for continued outpatient care with a qualified therapist or other healthcare providers;[3]  tracheostomy tube exchange is often performed every few months

Decannulation

This process depends greatly on patient and provider variables. General considerations include the following[3] :

  • Successful ventilator weaning can be done when promising patient characteristics (evidence of ability to protect airway) are observed
  • The tube is often downsized before removal; transition to a speaking valve or fenestrated tube may assist in reestablishing phonation
  • Eventually, the tube is capped for a trial period of up to a few days, making it necessary for the patient to breathe and speak through his or her natural airway; if the patient tolerates this trial well, the tracheostomy tube may be removed.

Complications

Complications of PCT mirror those of surgical tracheotomy. They can be divided into early and late complications. A simplified list is provided below. For more detailed information, please see the Complications section of Tracheostomy.

Early complications (intraoperative or postoperative)

These include the following[3, 23] :

  • Bleeding (most commons)
  • Intraoperative injury to nearby tissues
  • Apnea/hypoxia
  • Misplacement of the tube into the paratracheal space
  • Inadvertent removal
  • Tube occlusion
  • Airway loss
  • Subcutaneous emphysema
  • Pneumothorax
  • Infection

Late complications

These include the following[3, 23] :

  • Tracheoinnominate artery fistula
  • Tracheal stenosis
  • Tracheoesophageal fistula
  • Infection

Outcome and Prognosis

Because PCT is performed in critically ill patients, late outcome of the procedure is difficult to describe. The mortality rate is high, but this high rate is related to medical problems other than PCT. Death due to PCT or related complications is relatively rare.[24]  A prospective study by Vargas et al of patients who underwent elective PDT in the ICU indicated that patient age and the Simplified Acute Physiology Score (SAPS) II are each independently associated with ICU mortality.[25] Moreover, in comparison with patients with neurologic disease who underwent PDT, those in whom the procedure was administered as a result of respiratory disease had a higher ICU mortality rate (13.6% vs 50%, respectively).​

Conditions after PCT that significantly affect patients' lives and everyday activities are few. Of all the long-term complications that require operative correction, symptomatic tracheal stenosis is the most difficult to manage, although it is relatively rare (1.9%). Hoarseness and temporary voice changes have been reported by a significant number of patients (with a prevalence of up to 50%). In most cases, however, these changes are related to previous translaryngeal intubation. Direct injuries to the vocal cords or recurrent laryngeal nerve are extremely rare.

Small skin incisions and few adjacent anatomic structure injuries due to blunt tissue dissection can have favorable cosmetic results in stomal wound healing. Results of a study by Ikegami et al in which a patient questionnaire and door-to-door evaluations were used indicated that the closed fistula site in patients who had undergone PCT had a better appearance at long-term follow-up than it did in patients treated with surgical tracheotomy, even with regard to the frequency and degree of scar unevenness.[26]

Future and Controversies

PCT has undergone and continues to undergo rigorous evaluation regarding its safety and the simplicity of its techniques. New percutaneous methods, as well as modifications of the currently popular techniques, have continued to be developed. As new methods are introduced, future prospective, randomized clinical studies would be helpful. PCT has been shown to be a safe and viable alternative to the standard open tracheotomy technique. However, this method has its drawbacks and contraindications, and the surgeon performing PCT should be aware of them when choosing his or her approach.