Percutaneous Tracheostomy

Introduction

Endoscopic percutaneous dilatational tracheostomy (PDT) is a safe and simple bedside procedure that is particularly well suited to patients in the intensive care unit (ICU). Almost two-thirds of tracheostomies are performed in ICU patients. These critically ill patients, usually with multisystem disease are at high risk for complications. Moving these patients with their monitors and endotracheal tubes (ETTs) to the operating room (OR) for an open surgical tracheostomy (ST) carries several risks during transport. These risks include accidental extubation and vital sign changes requiring pharmacologic intervention.

Standard ST at the bedside in the ICU requires transporting instrument trays, adequate suction, extra lighting, and electrocautery from the OR. The procedure may be compromised by the lack of trained OR nurses and assistants. Risks include inadequate or difficult exposure and spontaneous ignition with the use of electrocautery in the presence of oxygen concentrations exceeding 30%.

Interest in a bedside percutaneous tracheostomy procedure led to the early development of several techniques, most of which were quickly abandoned. The development of a reliable bedside percutaneous dilatational technique in 1985 generated ongoing interest. The “blind” aspect of the procedure was later addressed by the addition of continuous endoscopic guidance. Endoscopic PDT requires no special lighting, no special equipment, and no electrocautery, and there is no need to move patients. My experience with more than 1500 of these procedures has demonstrated that, with bronchoscopic visualization and attention to technical detail, endoscopic PDT is a safe, cost-effective alternative to ST in the OR with comparable or lower complication rates.

1.
Technique based on progressive dilatation of a tracheal puncture
2.
Always performed with endoscopic guidance
3.
Only performed in adult, intubated patients in the ICU
4.
At least as safe as open ST

Key Operative Learning Points

1.
Always performed with endoscopic guidance
2.
Instruments should be held like a pen.
3.
Forceful dilatation is never indicated and usually means that there is a problem.
4.
Bleeding during the procedure is usually tamponaded by the tracheostomy tube.

Preoperative Period

History

1.
What is the nature of the current illness?
- a.
  Why is the patient intubated?
- b.
  What organ systems are involved?
- c.
  Is there trauma to the neck?
- d.
  Is the cervical spine stable?
- e.
  Has the patient had a recent thoracotomy?
- f.
  What is the patient’s physical status classification as per the American Society of Anesthesiology (ASA)?
- g.
  Is the patient currently on anticoagulants (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], antiplatelet agents, Coumadin)?
2.
Is tracheostomy indicated?
- a.
  Expected intubation for greater than 10 days
- b.
  Upper airway obstruction (e.g., trauma, neoplasms, subglottic stenosis)
- c.
  Prolonged mechanical ventilation (e.g., stroke, central nervous system [CNS] disorders, respiratory failure)
- d.
  Tracheobronchial toilet (e.g., chronic obstructive pulmonary disease, adult respiratory distress syndrome)
3.
Past medical history
- a.
  Previous tracheostomy
- b.
  Previous surgery, radiotherapy, or trauma to the neck/cervical spine, all of which may make the procedure more difficult
- c.
  Difficult or abnormal neck anatomy (e.g., kyphoscoliosis, cricoid cartilage at the sternal notch)
- d.
  History of midline neck masses, high innominate artery, large thyroid gland, or goiter
- e.
  Other comorbidities
- f.
  Medications, in particular anticoagulants, and herbal products that affect coagulation

Physical Examination

1.
Is the patient intubated?
2.
Body habitus: Obesity with a body mass index (BMI) greater than 30 is more technically challenging and associated with a higher complication rate.
3.
Neck extension: Are there limitations from anatomic abnormalities (e.g., kyphoscoliosis) or an unstable cervical spine? If so, an open ST should be performed in the OR.
4.
Anatomic landmarks: The thyroid and cricoid cartilages as well as the sternal notch must be palpable.
5.
Are the anatomic landmarks midline? If not, why?
6.
A low-lying cricoid cartilage makes the procedure more technically challenging.
7.
Are there any masses in the neck, neoplastic or otherwise, in the operative field? If so, an open ST should be performed in the OR.
8.
A high innominate artery in or very close to the operative field is an indication for an open ST in the OR.

Imaging

1.
A recent chest radiograph is useful in indicating a tracheal shift, lung abnormalities, or other anatomic aberrations that may affect the procedure.

Indications

1.
Adult intubated patients in a monitored setting: ICU, coronary care unit (CCU), or postoperative recovery room
2.
Percutaneous tracheostomy can be safely performed:
- a.
  In obese patients
- b.
  In patients with a prior history of tracheostomy, whether it was performed percutaneously or open

Absolute Contraindications

1.
Inability to palpate the cricoid cartilage above the sternal notch
2.
The presence of a midline mass in the neck (e.g., large thyroid) or goiter
3.
A high innominate artery
4.
Positive end-expiratory pressure requirement of greater than 15 cm H ₂ O
5.
Children
6.
Airway emergency, unsecured airway

Relative Contraindications

1.
Inability to correct the International Normalized Ratio (INR) to ≤1.5

Many ICU patients are on anticoagulants and for medical reasons cannot have their anticoagulation completely corrected preoperatively. Others have liver failure with associated coagulation defects. Percutaneous tracheostomy is the preferred procedure in these situations because of the small incision, blunt dissection, and tamponade effect of the tube.
2.
Inability to correct the platelet count to ≥50,000

Preoperative Preparation

1.
Comorbidities should be optimized.
2.
Preoperative testing is minimal and includes hemoglobin levels, INR, prothrombin time, partial thromboplastin time, and platelets. INR should be corrected to ≤1.5, and platelets should be corrected to ≥50,000 functioning platelets, whenever possible. Because blood loss tends to be minimal, a preoperative crossmatch is unnecessary, unless hemoglobin levels are extremely low (≤7). Similarly, preoperative transfusions are also unnecessary, even in the presence of low hemoglobin levels.
3.
Required personnel: surgeon, endoscopist (resident, ICU physician), nurse to administer medications, and a respiratory therapist to regulate ventilator settings
4.
Prepare the instruments on a Mayo stand in the order in which they are to be used.
5.
Consider the type/size of the tracheostomy tube:
- a.
  For most patients a size 6 internal diameter (I.D.) tracheostomy tube with an inner cannula works well.
- b.
  A size 8 I.D. tube may be necessary in patients with copious secretions.
- c.
  In obese patients or those with a “deep” trachea, a proximally extended tube will prevent accidental decannulation.

Operative Period

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here