A proposed novel ultrasound-guided percutaneous dilatational tracheostomy technique - the in-plane wire-in-needle approach: study design and rationale for multicenteric randomized controlled clinical trial


  • Mariam A. Alansari Department of Adult Critical Care Medicine, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh 11461, Kingdom of Saudi Arabia
  • Fadi Aljamaan Consultant Adult Intensivist Head of rapid Response Team Unit Department of Adult Critical Care Medicine King Khalid University Hospital College of Medicine King Saud University Riyadh, Kingdom of Saudi Arabia.




Ultrasound guidance, Percutaneous dilatational tracheostomy, Out-of-plane approach, In-plane approach, Needle visibility, Safety, Efficacy


Background: The current evidence regarding the applications of Ultra Sound (US) in Percutaneous Dilatational Tracheostomy (PDT) is encouraging. US guided PDT (US-PDT) has recently been recommended in difficult cases and is given a preference compared to bronchoscope guided PDT. The question on the difference in safety and efficacy of the different approaches in US-PDT (with or without the use of any technique to improve needle visualization) during US-PDT and whether it is likely to make a difference needs to be answered.

Methods: Literatures examining the different US-PDT approaches as well as whether any technique to improving needle visualization that has been used during US-PDT in MEDLINE, PubMed, EMBAS E, and the Cochrane Central Register of Controlled Trials were searched for in an attempt to answer the two questions raised. No study has yet compared the in plane to the out of plane approach for US-PDT nor looked at improving needle visualization during US-PDT. This raised the need for a clinical trial looking at the difference between the different US-PDT approaches with or without ways to improve needle visualization during US-PDT.

Results: Utilizing the best available evidence in US guided procedures in the Intensive Care Units (ICU), we proposed a study design that we think is likely to make a difference in US-PDT practice. The study is designed to assess the safety and efficacy of US guided PDT using the in-plane (I.P.) approach enhanced with the use of Wire-in-needle approach (W.I.N.A) and rocking motion of the transducer compared to the traditional out-of-plane approach without W.I.N.A.

Conclusions: The proposed (In-plane Wire-In-needle approach = I.P.W.I.N.A) as a potential to be a standard of care in US-PDT has its own limitations. Its safety, efficacy and feasibility in Randomized Controlled Clinical Trials research settings needs to be tested and verified.

Author Biography

Mariam A. Alansari, Department of Adult Critical Care Medicine, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh 11461, Kingdom of Saudi Arabia

MD, FRCSI, CCF, Consultant Adult Intensivist
Head of rapid Response Team Unit


Alansari M, Alotair H, Al Aseri Z, Elhoseny MA. Use of ultrasound guidance to improve the safety of percutaneous dilatational tracheostomy: a literature review. Critical Care. 2015;19:229.

Flint AC, Midde R, Rao VA, Lasman TE, Ho PT. Bedside ultrasound screening for pretracheal vascular structures may minimize the risks of percutaneous dilatational tracheostomy. Neurocrit Care. 2009;11:372-76.

Rudas M. The role of ultrasound in percutaneous dilatational tracheostomy. Australas J Ultrasound Med. 2012;15:143-8.

Gray AT. Ultrasound-guided regional anesthesia: Current state of the art. Anesthesiology. 2006;104:368-73.

Sites BD, Spence BC, Gallagher JD, Wiley CW, Bertrand ML, Blike GT. Characterizing novice behavior associated with learning ultrasound-guided peripheral regional anesthesia. Reg Anesth Pain Med. 2007;32:107-15.

Sites BD, Chan VW, Neal JM. The American Society for Regional Anesthesia and Pain Medicine and the European Society of Regional Anesthesia and Pain Therapy Joint Committee recommendations for education and training ultrasound-guided regional anesthesia. Reg Anesth Pain Med. 2010;35:S74–S80.

Slama M, Novara A, Safavian A, Ossart M, Safar M, Fagon JY: Improvement of internal jugular vein cannulation using an ultrasound-guided technique. Intensive Care Med. 1997;23:916-19.

Karakitsos D, Labropoulos N, De Groot E, Patrianakos AP, Kouraklis G, Poularas J, et al. Realtime ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10:R162.

Sites BD, Brull R, Chan VWS. Artifacts and pitfall errors associated with ultrasound-guided regional anesthesia. Part I: understanding the basic principles of ultrasound physics and machine operations. Reg Anesth Pain Med. 2007;32:412-8.

Szeto C, Kost K, Hanley JA, Roy A, Christou N. A simple method to predict pretracheal tissue thickness to prevent accidental decannulation in the obese. Otolaryngol Head Neck Surg. 2010;143:223-9.

Kundra P, Mishra SK, Ramesh A. Ultrasound of the airway. Indian J Anaesth. 2011;55:456-62.

Ambesh SP. Principles and Practice of Percutaneous Tracheostomy. Croatia: Jaypee Brothers Medical Publisher. 2010.

Smith J, Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound: Part 1. Fundamentals. PM R. 2009;1:64-75.

Smith J, Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound: Part 2. Clinical applications. PMR. 2009;1:162-77.

Schmidt U, Hess D, Kwo J, Lagambina S, Gettings E, Khandwala F. Tracheostomy tube malposition in patients admitted to a respiratory acute care unit following prolonged ventilation. Chest. 2008;134(2):288-94.

Polderman KH, Spijkstra JJ, de Bree R, Christiaans HM, Gelissen HP, Wester JP. Percutaneous dilatational tracheostomy in the ICU: optimal organization, low complication rates, and description of a new complication. Chest. 2003;123(5):1595-602.

Ayoub OM, Griffiths MV. Aortic Arch laceration: a lethal complication after percutaneous tracheostomy. Laryngoscope. 2007;117(1):176-78.

Grant CA. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review. Br J Anaesth. 2006;96(1):127-31.

Chacko J, Nikahat J, Gagan B, Umesh K, Ramanathan M. Real-time ultrasound-guided percutaneous dilatational tracheostomy. Intensive Care Med. 2012;38:920-1.

Rajajee V, Fletcher JJ, Rochlen LR, Jacobs TL: Real-time ultrasound-guided percutaneous dilatational tracheostomy: a feasibility study. Crit Care. 2011;15:R67.

Rudas M, Seppelt I: Safety and efficacy of ultrasonography before and during percutaneous dilatational tracheostomy in adult patients: a systematic review. Crit Care Resusc. 2012;14:297-301.

Schofer JM, Nomura JT, Bauman MJ, Hyde R, Schmier C. The Ski Lift: A Technique to Maximize Needle Visualization with the Long-axis Approach for Ultrasound-guided Vascular Access. Acad Emerg Med. 2010;17(7):e83-e84.

Stone MB, Mallin M, Cook J. Another WIN for point-of-care ultrasound: the wire-in-needle modified Seldinger technique for ultrasound-guided central venous access. Acad Emerg Med. 2013;20(6):E14-5.






Original Research Articles