Q: At what level of ventilator settings, surgically placed tracheostomy(ST) is preferred over bedside Percutaneous Dilational Tracheostomy(PDT)?


Answer:  Nothing beats an experienced operator irrespective of which technique is used. Though PDT is now considered as standard of care for tracheostomy but in few cases ST should be prefered over PDT. Three conditions deserve special attention. 

Firstly, coagulation abnormalities, since bleeding vessels are under direct vision in ST, and provides better control against any bleeding catastrophe. 

Secondly, high ventilator settings, particularly when FiO2 is at or above 70% or PEEP is at or above 10. 

Thirdly, obese patients with "no neck" or patients with previous surgery or mass in neck area.

In Trauma-ICU, added condition of unstable cervical spine need consideration of ST technique.