Percutaneous dilatational tracheostomy (PDT) has revolutionized airway management in intensive care units (ICUs). Its minimally invasive nature, ability to be performed bedside, and cost-effectiveness make it a preferred choice for patients requiring prolonged ventilation. However, as simple as it may seem, the success and safety of PDT hinge on one critical factor: the force applied during the procedure.

Emerging evidence highlights how excessive dilatational force can lead to catastrophic complications. Understanding this risk and adopting refined techniques such as controlled force application and pre-dilation dissection can significantly improve outcomes.

The Role of Dilatational Force

During PDT, the tracheal stoma is dilated to insert the tracheostomy tube. This process involves the application of force, often using instruments such as the Griggs forceps or Ciaglia Blue Rhino (CBR) dilator. While straightforward in concept, the force applied during dilation is a double-edged sword:
• Low Force: Ensures controlled dilation with minimal trauma to the tracheal rings and surrounding tissue.
• Excessive Force: Risks complications such as tracheal cartilage fractures, subcutaneous emphysema, pneumothorax, or even complete tracheal rupture.

A 2019 report highlighted two real-world cases of tracheal rupture during PDT, even when performed under bronchoscopic guidance. Excessive force or the operator’s inability to identify pre-rupture signs, such as anterior-posterior tracheal wall approximation, played a significant role in these complications.

What Research Reveals About Force Management

Recent studies have quantified the forces applied during PDT, providing insights into how experience and technique influence safety:
1. Force Profiles Differ by Expertise
• Experienced surgeons applied significantly lower forces, averaging 31.3 N (mean) compared to 48.8 N for less experienced operators.
• Procedures performed by experienced surgeons showed smoother and more consistent force curves, typically with a single peak indicating controlled dilation.
• In contrast, less experienced surgeons produced inconsistent force curves with multiple peaks, indicating poor positioning and increased tissue trauma risk.
2. Force Magnitude and Moments
• Axial force (P) was the dominant force during the procedure, but bending moments (Mx, My) and torque (Mz) were higher in less experienced operators, reflecting inefficient technique and potential for injury.
• The peak axial force reached up to 88.2 N in inexperienced hands, compared to 82.8 N in experienced ones—a critical difference when dealing with fragile tracheal structures.
3. Simulations Show the Path to Improvement
• Using a strain-gauge-equipped CBR dilator, researchers demonstrated that training and feedback could significantly reduce variability and improve procedural safety.

Why Some Dissection is Necessary

Pre-dilation dissection, though not always emphasized, can reduce the resistance faced during dilation:
• Clearing Tissue Resistance: Limited pre-tracheal dissection minimizes the force required to insert the dilator, reducing stress on tracheal rings.
• Avoiding Cartilage Damage: In cases of prolonged intubation or infection, tracheal rings may weaken or become flaccid, making them more susceptible to rupture even under normal force.

Both the 2018 experimental study and real-world cases from 2019 emphasize that minor preparatory dissection can make a substantial difference in procedural outcomes.

Training and Technology: The Future of Safer PDT

The studies also highlight the role of advanced tools and structured training in preventing complications:
1. Force-Sensing Dilators:
• Devices equipped with strain gauges provide real-time feedback on the forces applied, alerting operators when they exceed safe thresholds.
• Such tools can guide less experienced surgeons toward a safer, more consistent technique.
2. Simulation-Based Training:
• Using lifelike tracheostomy simulators, operators can practice applying optimal forces and refine their skills without putting patients at risk.
• Incorporating visual or auditory feedback during simulations can further enhance learning.
3. Standardized Techniques:
• Following well-defined procedural steps, including pre-dilation assessments and controlled force application, can minimize variability and ensure adherence to safety standards.

Takeaways for Clinicians
1. Excessive Dilatational Force Leads to Complications
• Tracheal rupture, cartilage damage, and post-procedure complications like tracheal stenosis are closely linked to higher force application.
2. Experience Matters
• Skilled operators use lower, more consistent forces, reducing procedural time and complication rates.
3. Pre-Dilation Dissection Improves Outcomes
• Small dissections before dilation reduce resistance and protect fragile tracheal structures.
4. Technology and Training Are Game-Changers
• Force-monitoring tools and simulation-based training can bridge the gap for less experienced practitioners, ensuring patient safety.

Conclusion

Percutaneous dilatational tracheostomy is a vital procedure in ICU care, but its success depends on precise execution. By understanding the risks of excessive force, embracing preparatory techniques like limited dissection, and leveraging modern training tools, clinicians can make PDT safer and more effective.

As research and technology continue to evolve, the future of PDT looks promising, offering new ways to standardize practices and reduce complications. Let’s work toward a safer, more consistent approach to this life-saving procedure.