tracheostomy is an elective technique in intensive care unit ( icu ) for the management of patients requiring prolonged mechanical ventilation ( mv ) .
operators skills , clinical anatomical and physio - pathological features of the patient should be evaluated before deciding to attempt the percutaneous dilation tracheostomy ( pdt ) technique .
we report three cases of pdt in which we attempted different methods in the light of different clinical features of each patient .
the aim of these reports is to emphasize the need for choosing the tracheostomy method adapted to the characteristics of each critically ill patient in order to reduce complications .
informed consent was obtained from the patients or their next of kin before each procedure .
an 83-year - old patient mechanically ventilated by endotracheal tube was admitted in our general icu because of acute respiratory failure due to chronic bronchitis .
mycotic pneumonia was diagnosed . due to weaning failure and persistent dependency on mv , the patient
surgical ts and translaryngeal ts ( tlt ) were excluded because neck palpation revealed cricoid prominence at jugular notch level , so the first tracheal ring was in a retro - sternal position . for
percutwist ts was excluded because of the short , rigid dilator ( 4 cm ) .
ciaglia blu - rhino ts set ( cbr ) was chosen along with total intravenous anesthesia ( tiva ) .
the guide wire was introduced through the needle between the first and second tracheal ring . because the cbr introducer catheter was too short to reach the tracheal lumen due to very long distance between jugular notch and the first tracheal ring , a central venous catheter ( 8.5 fr.x5 - 1/8  ) vessel dilator
was used to carry out the initial dilatation on the guide wire and to allow the placement of the white guiding catheter in the trachea .
the cbr dilator was not indicated because the distance from tracheal lumen to skin of the neck was 9 cm [ figure 1 ] .
it was necessary to advance beyond the black skin level mark of the dilator for proper dilatation of the tracheal wall and it appeared dangerous to pass it .
bc has long dilators with an extremely distal dilatation cone that allows deeper tracheal dilation .
an extra long - armed tube was placed to assure the correct positioning inside the tracheal lumen .
( b ) extra long - armed tube placed inside the tracheal lumen a 76-year - old - female patient mechanically ventilated with endotracheal tube in situ was admitted in our icu after craniotomy for a cerebellar haematoma .
the patient had mild ectasia of the ascending aorta and aortic regurgitation with de musset 's sign .
the anomaly of the aortic arch could be a contraindication to tracheostomy due to increased risk of perioperative bleeding .
the pulse was not transmitted but there was vascular ectasia encroaching onto the right sterno - clavicular articulation . following weaning failure on the 10 day of ventilation , we chose to perform a tlt because of the low bleeding risk of this technique . at the beginning of the procedure we placed the 4 mm i.d .
oro - tracheal tube by tube exchange with video endoscopy assistance , necessary for a modified tlt technique .
anatomical structures ( vessels , cartilage and bones ) were marked on the skin of the neck .
under endoscopic guidance and transillumination , vessels were identified in the free space between the tracheal rings for safe insertion of ts . since no vessel free space was seen under doppler , ts with paramedian access was decided .
so we chose a left side us guided entrance to perform the ts in the neck .
the stoma was placed about 2 cm from the aortic ectasia on the medial side of sternocleidomastoid muscle , and 2 cm from the left carotid artery .
on the 42 post - operative day the patient started spontaneous breathing through the tracheostomy tube with affixed artificial nose .
on the 55 day the patient was discharged from icu and referred to a respiratory rehabilitation recovery unit [ figure 2 ] .
( a ) anatomical structures marked on the neck skin and needle placed under us guide .
( b ) ts performed by a paramedian entrance a 49-years - old patient was admitted in our icu with diagnosis of chronic obstructive pulmonary disease and exacerbation with obstructive and restrictive respiratory failure .
the bronchoscopy , before the ts , detected tracheomalacia with inflammatory stenosis at the 4 tracheal ring , and the upper right lobar bronchus taking off from trachea instead of the right bronchus .
we chose to use ciaglia blue dolphin ( cbd ) balloon percutaneous tracheostomy introducer kit for a modified ts .
the dilator of this kit has a balloon on catheter tip which produces mainly radial force to widen the tracheostoma .
so after having performed the radial expansion through the cbd , the balloon was inserted through the stoma in the tracheal lumen to reach the stenosis at the 4 tracheal ring .
we decided to use the cbd 's balloon dilator to treat the stenosis by the expansion , before placing the tracheostomy tube .
then the second cuff of the ts tube was inflated with water to 11 atmospheres and it was used to dilate the tracheal stenosis .
the bronchoscopic view showed the dilatation of the stenosis and the proper position of the tracheostomy tube .
two checks , first at 10 days and then at 20 days after the procedure showed no recurrence of stenosis [ figure 3 ] .
an 83-year - old patient mechanically ventilated by endotracheal tube was admitted in our general icu because of acute respiratory failure due to chronic bronchitis .
mycotic pneumonia was diagnosed . due to weaning failure and persistent dependency on mv , the patient
surgical ts and translaryngeal ts ( tlt ) were excluded because neck palpation revealed cricoid prominence at jugular notch level , so the first tracheal ring was in a retro - sternal position . for
percutwist ts was excluded because of the short , rigid dilator ( 4 cm ) .
ciaglia blu - rhino ts set ( cbr ) was chosen along with total intravenous anesthesia ( tiva ) .
the guide wire was introduced through the needle between the first and second tracheal ring . because the cbr introducer catheter was too short to reach the tracheal lumen due to very long distance between jugular notch and the first tracheal ring , a central venous catheter ( 8.5 fr.x5 - 1/8  ) vessel dilator
was used to carry out the initial dilatation on the guide wire and to allow the placement of the white guiding catheter in the trachea .
the cbr dilator was not indicated because the distance from tracheal lumen to skin of the neck was 9 cm [ figure 1 ] .
it was necessary to advance beyond the black skin level mark of the dilator for proper dilatation of the tracheal wall and it appeared dangerous to pass it .
bc has long dilators with an extremely distal dilatation cone that allows deeper tracheal dilation .
an extra long - armed tube was placed to assure the correct positioning inside the tracheal lumen .
a 76-year - old - female patient mechanically ventilated with endotracheal tube in situ was admitted in our icu after craniotomy for a cerebellar haematoma .
the patient had mild ectasia of the ascending aorta and aortic regurgitation with de musset 's sign .
the anomaly of the aortic arch could be a contraindication to tracheostomy due to increased risk of perioperative bleeding .
the pulse was not transmitted but there was vascular ectasia encroaching onto the right sterno - clavicular articulation . following weaning failure on the 10 day of ventilation , we chose to perform a tlt because of the low bleeding risk of this technique . at the beginning of the procedure we placed the 4 mm i.d .
oro - tracheal tube by tube exchange with video endoscopy assistance , necessary for a modified tlt technique .
anatomical structures ( vessels , cartilage and bones ) were marked on the skin of the neck .
under endoscopic guidance and transillumination , vessels were identified in the free space between the tracheal rings for safe insertion of ts . since no vessel free space was seen under doppler , ts with paramedian access was decided .
so we chose a left side us guided entrance to perform the ts in the neck .
the stoma was placed about 2 cm from the aortic ectasia on the medial side of sternocleidomastoid muscle , and 2 cm from the left carotid artery .
on the 42 post - operative day the patient started spontaneous breathing through the tracheostomy tube with affixed artificial nose .
on the 55 day the patient was discharged from icu and referred to a respiratory rehabilitation recovery unit [ figure 2 ] .
( a ) anatomical structures marked on the neck skin and needle placed under us guide .
a 49-years - old patient was admitted in our icu with diagnosis of chronic obstructive pulmonary disease and exacerbation with obstructive and restrictive respiratory failure .
the bronchoscopy , before the ts , detected tracheomalacia with inflammatory stenosis at the 4 tracheal ring , and the upper right lobar bronchus taking off from trachea instead of the right bronchus .
we chose to use ciaglia blue dolphin ( cbd ) balloon percutaneous tracheostomy introducer kit for a modified ts .
the dilator of this kit has a balloon on catheter tip which produces mainly radial force to widen the tracheostoma .
so after having performed the radial expansion through the cbd , the balloon was inserted through the stoma in the tracheal lumen to reach the stenosis at the 4 tracheal ring .
we decided to use the cbd 's balloon dilator to treat the stenosis by the expansion , before placing the tracheostomy tube .
then the second cuff of the ts tube was inflated with water to 11 atmospheres and it was used to dilate the tracheal stenosis .
the bronchoscopic view showed the dilatation of the stenosis and the proper position of the tracheostomy tube .
two checks , first at 10 days and then at 20 days after the procedure showed no recurrence of stenosis [ figure 3 ] . ferraro .
the ts was placed quickly and safely , combining a good techniques of main procedures and devices available in icu . in this way , we avoided serious complications .
surgical ts and griggs techniques were excluded because of the retrosternal position of the first tracheal ring which may potentially have required a sternotomy .
the percutwist ts and the cbd were excluded because of the short dilator ( 4 and 5 cm respectively ) , and the cbr dilator was ineffective due to its shape .
tlt was excluded because once the first space between rings is reached by the needle , it would have been difficult to direct it through the larynx ( because of the acute angle between the tracheal axis and needle axis potentially causing dangerous traction on the tracheal tissue ) .
in addition , even if it had been possible to capture the guide wire with an endoscopical clamp and draw it out through the mouth by video bronchoscopy , some additional difficulties might have occurred during dilation and the drawing out of the cone - cannula . in the second case tlt was preferred because the cannula is stripped from inside to outside ( extrusive technique ) .
tlt is indicated in patients with a risk of bleeding ( anatomical peculiarities or altered coagulation ) .
furthermore the stoma tissue 's strong seal to the cannula , along with doppler us and transillumination guides , reduces bleeding risk . in the third case we chose cbd because the dilator allows the balloon tracheoplasty in the treatment of the stenosis with dual dilators effectively ( the balloon tipped introducer and the ts tube ) .
balloon tracheoplasty can be an effective or a temporary measure , as many patients require additional treatment .
we chose the most appropriate technique in relation to patient 's features and device characteristics .
it reduced the incidence of complications , and consequently the icu stay and costs in each of the three reported cases here .
generally inexperienced operators use techniques with which they are more familiar , but elective tracheostomy in icu can be delayed and carried out by experienced staff ensuring that the most suitable technique is applied and that this learning curve will be completed . however , a multicentre study is wanted in order to corroborate our modified techniques .
 there is no optimal tracheostomy ( ts ) technique , proved to be the best . for this reason , operators skills , clinical anatomical and physio - pathological features of the patient 
 should be considered as discriminating factors in the choice of percutaneous dilation tracheostomy ( pdt ) technique . 
 this article includes reports of three cases of pdt : in the first case distance between jugular notch and the first tracheal ring was too long , the second case involving a patient with mild ectasia of the ascending aorta and aortic regurgitation with de musset 's sign with great risk of perioperative bleeding and a third case , of tracheomalacia with inflammatory stenosis at the 4th tracheal ring . 
 all together , this case series describes how decisions were made by an experienced staff , in which the patient characteristics were assessed and techniques best suited for each case were implemented . 
INTRODUCTION
CASE REPORTS
Case 1
Case 2
Case 3
DISCUSSION
CONCLUSIONS