Percutaneous Dilatational Tracheostomy
Carlos A. Pelaez
Percutaneous dilatational tracheostomy is now the standard operative technique for long-term airway access at many institutions around the world. There are two slightly different technical approaches to this procedure, which differ primarily in the use or omission of bronchoscopic guidance. Both are discussed in this chapter.
SCORE™, the Surgical Council on Resident Education, classified tracheostomy as an ESSENTIAL COMMON procedure.
STEPS IN PROCEDURE
Check equipment including balloon of tracheostomy tube
Hyperextend the neck if no cervical spine injury
Bronchoscopic visualization of proximal trachea (optional)
Vertical incision (or horizontal) extending 2 cm inferiorly from cricoid cartilage
Palpate/visualize second and third tracheal rings
Insert needle into trachea and aspirate air
Advance catheter and pass guidewire (bronchoscopic control)
Pass lubricated dilator
Using dilator as obturator, pass lubricated tracheostomy tube and secure
Confirm placement, achieve hemostasis and secure the tube
COMPLICATIONS
Bleeding
Injury to posterior wall of trachea
Improper placement
Erosion into innominate artery/tracheoinnominate artery fistula
Tracheal stenosis
Percutaneous dilatational tracheostomy is generally not recommended for achieving emergency airway control or access. Endotracheal intubation or cricothyrotomy is the most appropriate emergency technique to achieve adequate airway control and ventilation. Percutaneous dilatational tracheostomy is a safe and appropriate technique for use in the intubated patient who requires elective tracheostomy. It may be done at the bedside in the intensive care unit, with direct visualization of the trachea or under bronchoscopic guidance.
Absolute contraindications to percutaneous dilatational tracheostomy include the following:
Patient younger than 8 years of age
Emergency airway due to acute airway compromise
Gross distortion of neck anatomy due to hematoma, tumor, large thyromegaly, or high innominate artery
Relative contraindications include the following:
Obese patient with short neck that obscures landmarks
Coagulopathy with prothrombin time or activated partial thromboplastin time more than 1.5 times the reference range, platelet count less than 50,000, or bleeding time longer than 10 minutes
Positive end-expiratory pressure (PEEP) of more than 20 cm of water
Infection of the soft tissues of the neck
Appropriate positioning and preparation of the patient are essential to achieving good operative results. Therefore, in both techniques, the following preparations must be made. Place the intubated patient in a supine position. Continuous monitoring should include electrocardiographic monitoring of heart rate, blood pressure, pulse oximetry, inspired title volume, and ventilator pressures. Increase the inspired oxygen fraction to 100% and ensure adequate ventilation. Extend the cervical spine by placing a rolled towel between the shoulder blades. In patient with cervical spine injury, the neck is kept in neutral position. This procedure is not considered sterile but one should always prep and drape the anterior neck with the solution of choice and sterile towels. The procedure is done with a preliminary cutdown and then a Seldinger technique, as summarized in Figure 4.1.
Percutaneous Dilatational Tracheostomy Without Bronchoscopic Guidance
Technical and Anatomic Points
Identify the anterior neck landmarks, including the thyroid and cricoid cartilages. Infiltrate the skin and subcutaneous tissues with 1% lidocaine solution with epinephrine before making the skin incision. Make the skin incision starting at the inferior edge of the cricoid cartilage and extending vertically 1.5 to 2 cm. Divide the subcutaneous tissues bluntly with hemostats at the level of the second and third tracheal rings until the trachea is visualized and its cartilage rings are palpable (Fig. 4.2). This allows for a clear visual delineation of tracheal anatomy, including the location of the tracheal midline, and obviates the need for concomitant bronchoscopy.
Achieve hemostasis with absorbable suture or electrocautery as necessary. Under laryngoscopic guidance, partially deflate the cuff of the endotracheal tube and slowly withdraw it until the cuff is seen just below the vocal cords. Stabilize the trachea in the midline and insert the needle and catheter this into the trachea between the second and third cartilage rings under direct vision. Confirm entry into the trachea by free aspiration of air. Advance the overlying catheter into the trachea and withdraw the needle. Again confirm the position of the catheter within the trachea by aspirating air. Advance the J-tipped guidewire through the catheter into the trachea (Fig. 4.3) and remove the catheter. Next, place a dilator guide over the guidewire, followed by a lubricated, tapered dilator up to its external 38 French mark (Fig. 4.4A,B). Perform this dilation carefully and without excessive force. Remove the dilator, leaving the dilator guide and guidewire in place. Pass a size 6 or 8 cuffed Shiley tracheostomy tube over the appropriate dilator, which will function as an obturator. Lubricate the tracheostomy tube and dilator and pass these into the trachea (Fig. 4.5). When the tracheostomy tube is seated in its final position, remove the dilator, dilator guide, and guidewire as a unit. Inflate the tracheostomy balloon until the air leak is sealed. Leave the endotracheal tube in place, but disconnect it from the ventilator. Connect the tracheostomy tube to the ventilator tubing with a flexible adaptor. Initiate ventilation. Confirm satisfactory oxygenation and minute ventilation before withdrawing the endotracheal tube. Apply the CO2 detector to ensure proper endotracheal position of the tracheostomy tube. Secure the tracheostomy tube by four-point fixation using sutures and a tracheostomy tape. Chest x-ray is not routinely necessary.
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