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Percutaneous Tracheotomy - Dilation

last modified on: Tue, 04/03/2018 - 09:08

Percutaneous tracheotomy
see also:
     Tracheotomy - Tracheostomy
     Open Tracheotomy in the Intensive Care Unit (includes discussion of Percutaneous vs Open Tracheotomy)
     Case Example Percutaneous Tracheotomy

 

  1. GENERAL CONSIDERATIONS
    1. Percutaneous tracheotomy is an elective procedure often performed at bedside in patients who are intubated.  
      1. In appropriately selected patients this procedure may causes less trauma to the patient
      2. It may be more cost effective than travelling to the operating room
        1. The billing for the procedure is less
        2. This procedure does not cost the surgeon valuable OR time
      3. It avoids the risk inherent in transferring patients across sites in the hospital
    2. A bedside Ultrasound of the neck was rarely used in the past, but has become more commonly used to the point that some recommend it as standard. It may be employed in unusual cases to identify any vascular structures or midline masses prior to performing the procedure.
    3. Performance of this procedure ideally includes preparation to convert to the standard open tracheostomy should complications arise.
    4. Comparison of percutaneous versus open surgical technique through a recent Cochrane Database of Systemic Reviews (July 20, 2016) identified "the results of this meta-analysis are limited and cannot be applied to all critically ill adults".(Brass 2016)

  2. INDICATIONS
    1. Need for ventilation support expected past 14 days
    2. Upper airway obstruction in patients whose airway has already been secured with intubation
    3. Pulmonary toilet - decreasing resistance to help wean patient from ventilator
  3. CONTRAINDICATIONS
    1. Although each case is individually assessed, the percutaneous tracheotomy is not generally performed on the following subset of patients:
      1. Emergent situations
      2. Patients with midline neck masses
      3. Obese patients
      4. The pediatric population
      5. Non-intubated patients
      6. Other relative contraindications: 
        1. PEEP value of greater than 20
        2. Uncorrected coagulopathy
  4. PREOPERATIVE PREPARATIONS
    1. A Shiley Percutaneous tracheotomy tube is selected and loaded onto the correct introduction catheter prior to the beginning of the procedure.
      1. The cuff on the special percutaneous Shiley tracheotomy tube is tested, and all portions of the tracheotomy tube is identified including the trach strap, inner cannula, and obturator.
        1. A 2-0 or 3-0 silk suture is obtained and on hand to secure the trach at the end of the procedure.
    2. Positioning:
      1. A shoulder roll may be placed to create neck extension (in patients without C-spine injuries) (alternatively positioning on the operating table with a neck extender behind the head offers more adaptability in positioning).
      2. Injection with 1% lidocaine with 1:100,000 epinephrine is done to the planned site of placement
      3. Surgical site is prepped and draped in the standard fashion
      4. Landmarks are identified by palpation (and/or ultrasound) and marked, including the:
        1. Thyroid cartilage, cricoid cartilage, sternal notch, and proposed incision line
      5.  A cautery pad is in place for possible use of the bovie
  5. NURSING CONSIDERATIONS
    1. Setting up and appropriate preparation are key
    2. Room setup:
      1. Bronchoscopist is at the head of bed. Ideally the bronchoscope is attached to a camera for projection on a viewing screen positioned to permit visualization by entire team.
      2. The primary surgeon is at the right side of bed, with headlight in place
      3. The assistant surgeon is at the left of bed, with Mayo stand and sterile Percutaneous tracheotomy tray
    3. Equipment from the OR:
      1. Headlight, 
      2. Monopolar cautery machine, handpiece, grounding pad and a guarded monopolar blade.
      3. 2-0 or 3.0 silk suture for securing the trach following the procedure
      4. Obtain a tracheotomy kit for emergent purposes
    4. Order from Stores: 
      1. Order a a Shiley Mallinckrodt percutaneous trach - 8.0 and 6.0 cuffed tracheotomy tubes
      2. Ciaglia Blue Rhino percutaneous tracheotomy introducer kit
  6. ANESTHESIA CONSIDERATIONS
    1. Ventilation parameters should be adjusted to compensate for introduction of the bronchoscope during the procedure
      1. This adjustment may include the use of 100% oxygen
      2. All patients undergoing this procedure should have had their airway previously secured.  If the endotracheal tube is somehow dislodged during the procedure, the correct replacement protocol should be known.
    2. Intravenous analgesics determined by anesthesia team - may include:
      1. including Fentanyl
      2. Anxiolytics
      3. Short acting paralytics
  7. OPERATIVE PROCEDURE
    1. The proposed suture line is injected with 1% Lidocaine containing 1:100,000 Epinephrine 
      1. The underlying tissue is also infiltrated as well.
    2. A 2.0 cm incision is made overlying the 2nd-3rd tracheal rings
      1. Placement between the 1st and 2nd tracheal rings is also acceptable
    3. Subcutaneous tissues may be separated bluntly using hemostats at this point in time
      1. The underlying tracheal rings are then identified through palpation
    4. The bronchoscope is then passed through the endotracheal tube at that point in time
      1. The video screen (when available) for viewing through the bronchoscope is positioned so that the entire interventional team can visualize the airway
    5. A 15 gauge introducer needle on a saline filled syringe is inserted at midline. 
      1. The anterior tracheal wall is identified using the needle tip (see video of procedure done under general anesthesia: Case Example Percutaneous Tracheotomy 
        1. The membranous tracheal ring is identified at midline between the 2nd and 3rd, or 1st and 2nd tracheal rings
          1. It is ideal to enter through the membranous ring to
            1. allow for dilation
            2. to prevent fracture of calcified tracheal rings with subsequent airway obstruction
      2. The airway is entered under direct visualization of the bronchoscope
        1. The syringe is drawn back to ensure the needle tip is in the airway, confirmed by direct visualization
          1. *Note: entering directly at midline, at 90 degrees facilitates subsequent placement of the trach
          2. The needle tip should be identified under visualization prior to entering the airway
        2. Care must be taken to avoid puncturing the posterior tracheal wall
    6. The needle is removed, and the outer catheter is left in place
      1. The J wire is then threaded in through the catheter into the lumen of the trachea to the level of the carina
      2. The sheath is removed with the wire left in place.
    7. The 14 french introducer dilator is then passed over the wire guide to dilate the initial access site
      1. Some compression of the anterior tracheal wall is expected
    8. This is then replaced with the white 8 french guiding catheter over the guide wire once again.  This is advanced until the safety ridge is at the level of the skin.
    9. Lubricate the dilator by dipping the tip into the
    10. Advance the blue rhino dilator over the wire guide catheter.  Advance the distal tip of the dilator to the safety ridge of the guiding catheter.  Advance the dilator with a curved arching motion into the trachea and advance to the level of the dilation ring. This should be performed under bronchoscopic visualization.
    11. The cuff on the tracheostomy tube is completely deflated, and the tube is lubricated, while still on the appropriate blue loading dilator.  It is then passed over the loading J-wire unit, again to the safety ridge, and then into the airway.  This is also performed under direct bronchoscopic visualization.
    12. The blue dilator, guiding catheter, and J wire are removed.
    13. The inner cannula is inserted and the cuff is inflated.  The endotracheal tube is then removed, and the tracheotomy tube is secured into place with four corner sutures using 2-0 silk. 
  8. POSTOPERATIVE CARE
    1. Chest radiograph is optional but may be useful in appropriate cases
    2. A drain sponge should be positioned with the understanding that the suturing of the tracheostomy tube (as is required for percutaneous trachs) may make placement problematic
    3. The obturator should be retained with the patient (at the HOB) for emergent replacement
    4. The cuff should be deflated 24 hours following the procedure in non-ventilated patients
    5. Tracheotomy tube should be changed on day 7 for percutaneous trachs. (open tracheotomies with Bjork flaps may permit safe tracheotomy changes at shorter intervals in that percutaneous tracheotomies have not developed surgical planes created in the open tracheostomy procedure.###  
  9. SUGGESTED READING

    Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest. Jun 1985;87(6):715-9.

    Massick DD, Yao S, Powell DM, et al. Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy. Laryngoscope. Mar 2001;111(3):494-500.

    Kost KM. Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases. Laryngoscope. Oct 2005;115(10 Pt 2):1-30.

    Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. Mar 2007;117(3):447-54.

    Lore JM. The trachea and mediastinum: tracheostomy. In: Atlas of Head and Neck Surgery. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1988:811-818.
    Wenig BL, Applebaum EL. Indications for and technique of tracheotomy. Clin Chest Med. 1991;1293:545-553.

 Brass P, Hellmich M, Ladra A, Ladra J and Wrozosek A: Percutaneous techniques versus surgical techniques for tracheostomy Cochrane Database of Systematic Reviews July 20, 2016 (TI: Percutaneous techniques versus surgical techniques for tracheostomy SO: Cochrane Database of Systematic Reviews YR: 2016 NO: 7 PB: John Wiley & Sons, Ltd CC: ANAESTH DOI: 10.1002/14651858.CD008045.pub2)