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Percutaneous tracheostomy is now a well established technique used in the critical care setting. In general it is an elective procedure, and not suitable for the emergency airway, although this has been described.
Although the technique may be performed blind, whenever possible the trachea should be visualised via an intubating fibreoptic laryngoscope passed down the tracheal tube. Two operators are required for the procedure, one performing the tracheostomy, and one at the head of the patient looking after the airway, anaesthesia and bronchoscopy.
The percutaneous trachesotomy set illustrated is manufactured by Cook Critical Care, although other sets are available. It consists of a Seldinger type needle & wire, over which a guide and then series of dilators are passed.
In addition to the equipment given, one also needs:
- Sterile field & cleaning fluid
- Lubricating jelly (plenty of)
- Local anaesthetic with adrenaline
- Tracheal dilator
- Fibreoptic laryngoscope/bronchoscope
- Catheter mount to accept scope
- Intravenous anaesthesia
Although inhalation anaesthesia is possible, a total intravenous technique provides much smoother anaesthesia and better conditions for performing the bronchoscopy and tracheostomy. A combined propofol and opioid technique is a favoured option. Full monitoring is instituted, and ventilatory parameters altered during the bronchoscopy to maintain adequate oxygenation and end-tidal CO2 levels.
Following induction of anaesthesia, the patient is prepped and draped. The bronchoscope is passed through a tracheal tube and the anatomy of the airway visualised. The aim of the fibreoptic scope is to ensure correct initial placement of the introducer needle, in the midline and through the second or third tracheal rings. Subsequent to this, it will monitor dilation of the trachea, and ensure the introducer is not remains in the trachea.
Although not necessary for the procedure, information from bronchoscopy is very useful and it should always be used when learning the technique.
The patient is positioned with the neck extended, with a intravenous fluid bag between the shoulder blades and the head in a head ring. This brings as much of the trachea as possible into the neck. The important landmarks have been drawn on the patient below.
The larynx (hatched) and cricoid cartilage with the intervening cricothyroid membrane are identified. The suprasternal notch has also been marked. From the cricoid, moving caudally, the tracheal rings are identified. The tracheostomy should ideally pass between the second and third tracheal rings, although a space one higher or lower may be employed. Placing the airway higher, next to the cricoid can cause tracheal erosion and long term problems.
Local anaesthetic with adrenaline is infiltrated subcutaneously, and a 1cm incision made horizontally with a scalpel. Keeping in the midline at all times, the introducer needle and syringe are advanced, at 45 degrees to the skin, until air is aspirated from the trachea.
The guidewire is passed through the needle, then the small dilator (green) is passed. this is then removed and the white introducer passed into the trachea. The guidewire is removed. Now only the white introducer is left in the trachea.
Over this the tracheal dilators (blue) are passed in order, gradually dilating the incision to accommodate the appropriately sized tracheostomy tube. Plenty of lubricating jelly is applied to each dilator, and they are passed down the tract with a twisting motion. Only moderate downward force is applied. If the dilator does not pass easily, return to the previous smaller dilator and ensure it passes freely and easily. Often it is the skin that impedes progress, and the incision has to be slightly widened with the scalpel.
Each size of tracheostomy tube has a corresponding dilator size (see the manufacturers instructions), and this should pass freely and easily into the trachea before attempting to insert the tracheostomy tube.
Once the tracheostomy will easily accept the final dilator, the tracheostomy tube (cuff already checked) is loaded onto the dilator one size lower. The tracheal tube is wathdrawn, under direct vision, into the larynx, and the tracheostomy tube is passed over the introducer into the trachea. Once again, undue force should not be necessary. Use plenty of jelly and if required return to the previous dilator.
The use of the tracheal dilator instruments is rarely necessary, and may be hazardous. However, if the introducer is inadvertently pulled out of the trachea, or some other mishap occurs, they may be useful in relocating the tract for replacement.
With the tracheostomy tube in place, the tracheal tube is removed and the ventilator is connected to the tracheostomy. The chest is auscultated for adequate ventilation and the ventilator checked for appropriate tidal volumes and airway pressures. The tube is secured with tapes or ties.
- Gaglia P, Firsching R, Syniec C: "Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report" Chest 87:715-719, 1985
- Paul A et al: "Percutaneous endoscopic tracheostomy" Ann Thorac Surg 47:314-315, 1989
- Gaglia P, Graniero KD: "Percutaneous dilatational tracheostomy. Results and long-term follow-up [see comments]" Chest 101:464-7, 1992