Landmark-Guided Percutaneous Tracheostomy Without Visualization in Resource-Limited Settings

Objectives: Percutaneous dilatational tracheostomy (PDT) is increasingly preferred in intensive care due to its procedural efficiency. Standard approaches typically rely on real-time bronchoscopic or ultrasound guidance, which may be unavailable in resource-limited settings. We evaluated the feasibility, safety, and learning curve of landmark-guided PDT performed without adjunctive visualization. Methods: We retrospectively analyzed 71 consecutive adult patients who underwent landmark-guided PDT without bronchoscopic or ultrasound guidance between August 2024 and June 2025. All procedures were performed by a head and neck surgeon newly trained in PDT. Outcomes included procedure duration, complication rates, and patient-specific predictors of procedural difficulty. The learning curve was assessed using correlation and linear regression, and independent predictors of prolonged procedure time were identified through multivariable linear modeling. Results: The median procedure time was 7.0 (3.0–54.0) min, and a significant learning curve was observed (r = −0.41; p < 0.001). Complications occurred in 14.1% of patients, with major events being limited to one bleeding episode and two pneumothoraces. In multivariable analyses, prior cerebrovascular accident and increased cricoid–manubrium distance independently predicted prolonged procedure times. Conclusion: Landmark-guided PDT without real-time visualization was feasible and safe following a brief learning phase. With appropriate patient selection and operator training, this technique may represent a practical alternative in settings where visualization adjuncts are unavailable. Level of Evidence: 4.