E BRIEF REPORT

Percutaneous Dilatational Tracheostomy Using Tube

Exchanger
Ohad Ronen, MD,*† Alexander Gurevich, MD,‡ Shimon Ivry, MD,‡ Edward Altman, MD,§
and Evgeni Kukuev, MD‡

We describe a modified technique for percutaneous dilatational tracheostomy using a 15F tube
exchanger or Eschmann catheter. A retrospective review of 1180 procedures using this modi-
fied technique demonstrated it to be effective with a failure rate of only 0.25% (3 patients).
Moreover, it provides an additional safeguard with the ability to rapidly reintroduce the endotra-
cheal tube into the trachea guided by the exchange catheter in the event of accidental extuba-
tion during the procedure. This technique needs no additional special devices or equipment (eg,
a bronchoscope). However, a prospective study is needed to better define its complication rate. 
(Anesth Analg XXX;XXX:00–00)

P
ercutaneous dilatational tracheostomy (PDT) is often
­considered the preferred method for tracheostomy.
This cost-effective technique is widely undertaken
bedside with a low incidence of complications when com-
pleted by experienced operators.1 Because there are few
absolute contraindications (infants, unstable cervical spine
injuries)2 to PDT, this approach is broadly applicable to
many critically ill patients. In that setting, loss of the secured
airway remains one of the most potentially serious compli-
cations during the PDT procedure.
Because patients are already intubated at the beginning
of the PDT procedure, the endotracheal tube (ETT) must be
partially withdrawn to create a space for the insertion of the
guide needle and eventually for the tracheostomy tube. In a
situation in which the ETT is not sufficiently retracted, the
initial needle insertion may puncture the ETT, its cuff, or
even a guiding bronchoscope. However, if the ETT is with-
drawn excessively, the patient may become extubated with
loss of a secure airway necessitating emergency rescue mea-
sures. The aim of our technique is to use a tube exchanger
(rather than a bronchoscope) to guide the controlled with-
drawal of the ETT, which simultaneously facilitates the
ability to rapidly reintroduce the ETT into the trachea if
there is a loss of the airway. Moreover, our technique can
be readily performed by a single surgeon in addition to the
anesthesiologist and needs no additional devices or special
equipment.
METHODS
The trial has been approved by the Galilee Medical Center
Institutional Review Board (NHR0097417 on June 2017).
Written informed consent was waived by the Institutional
Review Board.
From the *Department of Otolaryngology, Head and Neck Surgery, Galilee
Medical Center, Nahariya, Israel; †Azrieli Faculty of Medicine, Bar-Ilan
University, Safed, Israel; ‡Department of Anesthesiology, Galilee Medical Center,
Nahariya, Israel; and §Surgery B, Galilee Medical Center, Nahariya, Israel.
Accepted for publication January 22, 2018.
Funding: None.
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Ohad Ronen, MD, Department of Otolaryngol-
ogy, Head and Neck Surgery, Galilee Medical Center, POB 21, Nahariya
2210001, Israel. Address e-mail to ohadr@gmc.gov.il.
Copyright © 2018 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000003321
Modified PDT Technique
The patient is sedated per routine. A fiberoptic bronchoscope
swivel connector (Smiths Medical, Keene, New Hampshire)
is placed at the proximal end of the ETT, so the patient can
be ventilated throughout the procedure. After optimally
positioning the patient, the surgeon prepares a sterile field
and drapes the surgical site. The anesthesiologist inserts a
15F tube exchanger into the patient’s ETT via the swivel
connector and deflates the ETT cuff. The ETT can now be
withdrawn completely outside the larynx, either by follow-
ing its measurement at the corner of the mouth or by feeling
the cuff against the vocal cords. Its cuff is inflated again and
slid back into the larynx with the tube exchanger directing it
safely between the vocal cords. The ETT reaches its position
with the cuff above the vocal cords and its tip at the level of
the subglottis, just below the vocal cords (Figure). Lidocaine
anesthetic is injected into the skin over the anterior trachea
immediately before the PDT guide needle is advanced and
punctures the trachea. Note that the tube exchange catheter
permits a more assertive withdrawal of the ETT to further
diminish the likelihood of needle puncture of the ETT or its
cuff. Furthermore, the ETT is gently moved in and out as
well as rotated to eliminate the possibility of a needle punc-
ture of the distal ETT. The rest of the procedure is performed
in accordance with conventional PDT techniques without
the need for any specific bronchoscopic guidance.3 When
PDT is finished, the tube exchanger and ETT are removed
together.
Study Design
The study was performed in 3 parts.
We first conducted an experimental qualitative in vitro
study. To estimate the optimal size of the tube exchanger
for different-sized ETTs, we performed a simulation during
mechanical ventilation of a training test lung with measure-
ment of basic parameters. A 15F catheter was determined to
be optimal.
Next, after informed consent was obtained, we con-
ducted a prospective pilot study that lasted 4 months. We
performed PDT using our technique in 30 consecutive
mechanically ventilated critically ill patients. In the first
group of 15 patients, we used the standard technique with a
bronchoscope for PDT.2 In the second group of 15 patients,
we used the 15F tube exchanger to guide manipulation
of the ETT, along with the standard PDT technique. The

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 EE Brief Report

following parameters were recorded during mechanical
ventilation in both groups: set tidal volume, delivered tidal
volume (to assess air leak), cuff volume, oxygen saturation,
and depth of ETT insertion (in cm). In the second group
of 15 patients, we routinely and intentionally reintubated
patients with the ETT over the 15F tube exchanger and iden-
tified no problems.
In the third part of the study, we retrospectively reviewed all
the PDT procedures using a tube exchanger performed at our
institution by physicians of the Otolaryngology Department
in intensive care units of our 750-bed academic center. All
procedures took place between 2006 and 2016. Using our
electronic medical record system, 1180 patients were identi-
fied. A chart review was done to identify complications and
procedure-related mortality. The complete patient record was
then examined for any evidence of surgical interventions for
long-term tracheal complications or related deaths.
Statistics Analysis
Quantity data were described by means and standard
deviation. Qualitative data were described by frequen-
cies and percentages. A 2-sided CI for proportions (using
the Binomial distribution) with 95% confidence level was
calculated for the failure rate. T test was used to compare
the measures between the ETT positions. P value <5% was
considered significant. Two-sided P value was presented.

Figure. Sagittal illustration of the tube exchanger inside the ETT
during percutaneous dilatational tracheostomy. The ETT cuff is posi-
tioned just above the vocal cords thereby avoiding the possibility of
accidentally puncturing the cuff while the tube exchanger prevents
inadvertent extubation. Courtesy of Amiel A. Dror. ETT indicates
endotracheal tube.
RESULTS
During the in vitro study, we determined a 20F tube
exchanger created excessive airway pressures, whereas the
15F catheter had minimal impact on ventilation through
either a 7.5- or 8-mm ETT. For this reason, we used the 15F
tube exchanger throughout the rest of the study.
During the prospective pilot study, our data suggested
that the presence of the tube exchanger did not adversely
impact ventilation or oxygenation (Table). When the tube
exchanger was in place, there were statistically significant
differences in mean air leakage and mean airway resistance
between the 3 positions: baseline, after insertion of the
tube exchanger, and cuff over the vocal cords. Because the
PDT procedure lasts only several minutes, it had no clini-
cal significance. A minimal, nonsignificant change in mean
minimal blood oxygenation and in mean maximal end-tidal
carbon dioxide was measured.
Using the standard PDT technique, we encountered sev-
eral problems including displacement of the ETT into the
pharynx (3 cases), rupture of ETT cuff (1 case), and fixa-
tion of ETT by the PDT guidewire through the Murphy eye
(1 case). Thereafter, we routinely used the 15F tube exchanger
or 15F Eschmann tracheal tube introducer for bedside PDT.
During the following 10 years, we performed 1180 percuta-
neous dilatational tracheostomies using only this technique.
The failure rate of PDT was 0.25% (3 patients). A CI for the
failure rate (3/1180) is 95% CI (0.09%–0.74%). There were
no needle punctures of either the ETT or the ETT cuff. There
were no procedure-related deaths. Pneumothorax devel-
oped in 1 patient, and 2 patients had excessive bleeding in
the first 24 hours that necessitated surgical intervention (1 at
bedside and 1 in the operating room).

Table.  Results of the Prospective Pilot Study

A. Before Insertion of B. After Insertion of Tube C. With ETT Cuff Over
Tube Exchanger (n = 30) Exchanger (n = 30) Vocal Cords (n = 30)
Air leak in mL ± SD (% of Vt) 30 ± 1.8 (5.8%) 68 ± 2.8 (14.7%)a 84 ± 3.5 (20.1%)b,c
Minimal Spo2 (%) 98% ± 1.6 98% ± 0.7 97% ± 1.7
Maximal Etco2 (mm Hg) 39.2 ± 1.3 40 ± 2.3 40.4 ± 1.1b
Mean airway resistance (cm H2O × s/L) 10.4 ± 0.8 32.7 ± 2.0a 36.4 ± 2.0b,c
During a prospective pilot study on 30 patients, the following parameters were measured at baseline, after insertion of the tube exchanger, and with the ETT cuff
in its position during the PDT: air leakage, changes in airway resistance, So2, and Etco2.
Abbreviations: Etco2, end-tidal carbon dioxide; ETT, endotracheal tube; So2, oxygen saturation; Vt, tidal volume.
a
P < .001 columns A versus B.
b
P < .001 columns A versus C.
c
P < .001 columns B versus C.

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 Percutaneous Tracheostomy Using Tube Exchanger
DISCUSSION
We present a novel adaptation to the usual PDT technique.
Our retrospective mortality and morbidity data compare
favorably with that seen in a prior series (around 5% bleed-
ing and 5% decannulation/obstruction).1,4–7 The major limi-
tations of our study are its retrospective nature and the lack
of randomized controls. Using this technique, the ability to
effectively ventilate patients is decreased, but since the PDT
procedure lasts only several minutes, this has no significant
clinical implications. Our modified technique minimizes
the risk for ETT or cuff puncture. Moreover, if the patient
is accidentally extubated, the tube exchanger is a reliable
guide for rapid reintroduction of the ETT into the trachea.
This creates a sense of confidence for the anesthesiologist
and surgeon, and encourages an “optimal” withdrawal of
the ETT during the procedure. This PDT technique requires
only a single surgeon in addition to the anesthesiologist. E
DISCLOSURES
Name: Ohad Ronen, MD.
Contribution: This author helped draft the article, analyze the data,
and conduct critical review of the manuscript.
Name: Alexander Gurevich, MD.
Contribution: This author helped collect and interpret the data and
conduct critical review of the manuscript.
Name: Shimon Ivry, MD.
Contribution: This author helped interpret the data and conduct
critical review of the manuscript.
Name: Edward Altman, MD.
XXX 2018 • Volume XXX • Number XXX www.anesthesia-analgesia.org
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Copyright © 2018 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Contribution: This author helped collect and interpret the data and
conduct critical review of the article.
Name: Evgeni Kukuev, MD.
Contribution: This author helped collect and interpret the data and
conduct critical review of the manuscript.
This manuscript was handled by: Nikolaos J. Skubas, MD, DSc,
FACC, FASE.
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