Practice Essentials
Tracheotomy, as a means of airway access, is one of the oldest surgical procedures documented, dating back approximately 4000 years. However, it wasn’t until the early 20th century, when Chevalier Jackson introduced clear guidelines, that tracheotomy was deemed a safe and viable procedure. With advances in technology and increasing interest in minimally invasive procedures, variations of the standard open tracheotomy have evolved over the last several decades.
Since Ciaglia et al introduced the percutaneous dilatational tracheotomy (PDT), in 1985, PCT has become increasingly popular and has gained widespread acceptance in many intensive care units (ICUs) as a viable alternative approach. [1, 2] In some institutions, percutaneous tracheotomy (PCT) has become the procedure of choice.
PCT should generally be considered an elective procedure. Although emergent application of PCT has been reported in the literature, one might be better off considering a cricothyroidotomy, given its relative ease of performance and the limited need for specialized equipment to complete the task. The overall goal in such patient care, regardless of how it is achieved, is to provide a long-term, secure airway and to take into account airway protection, maintenance, and pulmonary toilet.
Providers wishing to perform PCT must have proper training; this includes training in (and comfort with) the control of unexpected bleeding, alternatives to the planned procedure (should complications arise), relevant anatomy, and follow-up care of the tracheotomy. The provider must know when to downsize and decannulate and how to diagnose and manage complications such as tracheal stenosis, innominate artery stenosis, or tracheoinnominate fistula formation.
Most PCTs are performed rather quickly and with few immediate complications. However, as with any invasive procedure, substantial risks are involved; these include bleeding, infection, injury to nearby aerodigestive structures, and catastrophic airway loss leading to hypoxia, anoxia, or even death. However, in well-trained hands, the procedure can be safely carried out at the bedside in the intensive care setting or in the operating room. Variations in technique stem from surgeon preference regarding the available pre-packaged supplies, as well as individual experience.
Multiple studies that provide clear support for the less invasive percutaneous methods have been published. The most consistently reported benefits include decreased rate of surgical site infection, reduced operative time, and lower procedure cost. [3] Although it is beyond the scope of this article, the actual timing of the procedure depends on numerous factors. Ultimately, the physician providing the long-term ventilator care will determine the proper time to undertake this advanced airway procedure.
History of the Procedure
The percutaneous airway techniques that were developed not long after Seldinger described needle replacement over a guidewire for arterial catheterization (1953) have evolved to the present-day versions. In 1955, Shelden et al reported the first attempt to perform PCT. [4] They gained airway access with a slotted needle that then was used to guide a cutting trocar into the trachea. Unfortunately, the method caused multiple complications, and fatalities were reported secondary to the trocar's laceration of vital structures adjacent to the airway.
Percutaneous airway access methods have subsequently improved, and various techniques and refinements have been reported.
Although a tracheotomy technique based on a single tapered dilator with a recessed cutting blade was reported as early as 1969, [1] several variations of PCT appeared in the years that followed. [5, 6, 7]
Then, in 2000, Byhahn et al introduced the Ciaglia Blue Rhino technique, which is a modified version of the Ciaglia technique. [8] When this procedure is used, dilation of the stoma is formed in a single step, utilizing a curved, tapered dilator coated with hydrophilic material—the Blue Rhino. This method reduces the risks of posterior tracheal wall injury and intraoperative bleeding, as well as the adverse effects on oxygenation caused by repeated airway obstruction during serial dilation.
Some of the most recent techniques were developed in the mid-2000s and include the PercuTwist technique [9] and a balloon dilation technique. [3] Among the various PDT techniques developed, the Ciaglia Blue Rhino method is probably the most commonly used worldwide.
Indications
In the ICU, the most common indication for tracheotomy is the need for prolonged mechanical ventilation, occurring in 5-10% of the ICU population. [3] This need may arise from pneumonia refractory to treatment, severe chronic obstructive pulmonary disease, acute respiratory distress syndrome, severe brain injury, smoke inhalation injury, or multiple organ system dysfunction. The Council on Critical Care of the American College of Chest Physicians recommends tracheotomy in patients who are expected to require mechanical ventilation for longer than 7 days.
Indications for PCT are the same as those for standard open tracheotomy. Please refer to the Medscape Drugs & Diseases article Tracheostomy to review the main advantages of tracheotomy over prolonged translaryngeal intubation.
Airway obstruction may be due to the following:
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Inflammatory disease
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Congenital anomaly (eg, laryngeal hypoplasia, vascular web)
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Foreign body that cannot be dislodged with Heimlich and basic cardiac life support (BCLS) maneuvers
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Supraglottic or glottic pathologic condition (eg, neoplasm, bilateral vocal cord paralysis)
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Laryngeal trauma or stenosis
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Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the midface and mandible)
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Edema (eg, trauma, burns, infection, anaphylaxis)
Indications for PCT also include the following:
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Need for prolonged mechanical ventilation in patients experiencing respiratory failure
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Need for improved pulmonary toilet
Inadequate cough due to chronic pain or weakness
Aspiration and the inability to handle secretions (The cuffed tube allows the trachea to be sealed off from the esophagus and its refluxing contents. However, some argue that secretions can leak around the cuffed tube and reach the lower airway.)
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Prophylaxis (as in preparation for extensive head and neck procedures and the convalescent period)
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Severe sleep apnea not amenable to continuous positive airway pressure (CPAP) devices or other, less invasive surgery
Special consideration is required for creation of a tracheotomy in patients with burn injuries. Such individuals may require surgical control of the airway immediately after injury and on a long-term basis as the injuries heal. In the acute setting, neck burns often accompany facial burns, and both facial and neck burns are commonly associated with inhalation injury. In patients with burns who arrive intubated, but with risk of loss of airway due to ensuing facial edema, tracheotomy may be indicated.
Although there is no strict contraindication for percutaneous (dilatational) tracheotomy in patients with burn injuries, the physician is cautioned about performing it in these individuals. The edema accompanying deep burns of the anterior neck can result in loss of tissue planes and increase the difficulty of the operation. Added to this is the risk of loss of an orotracheal or nasotracheal tube already in place. Because the risk of airway loss is significant, extreme caution is advised. As with other patients with complicated injuries and those at high risk for poor outcomes, a formal tracheotomy performed in the operating room may be a better option.
Contraindications
Determination of absolute and relative contraindications remains a matter of debate. In most published articles, cervical injury, pediatric age, coagulopathy, and a need for an emergency airway are considered absolute contraindications, whereas a short, fat neck and obesity are relative contraindications. However, there have been several reports suggesting that performance of PCT in patients with the previously described contraindications can be safe and feasible. [10, 11, 12, 13, 14, 15, 16]
In a retrospective study, Blankenship et al suggested that PCT may be performed safely in a patient with morbid obesity as long as anterior neck landmarks can be palpated and in a patient with coagulopathy who has a platelet count as low as 17,000 and an international normalized ratio of 1.7. [10] Tabaee et al demonstrated the safety of PDT in patients with short neck lengths in their prospective, randomized study. [15] PCT was found to be safe and feasible even in emergency trauma cases in a case series study by Ben-Nun et al, [12] while Gravvanis et al [13] showed, in their retrospective study, that PCT can be safely and more rapidly performed in patients with burns and associated inhalation injury at the bedside. PCT was also found to be safe and feasible in patients with cervical spine fractures in a case series by Ben-Nun and colleagues. [14]
Kornblith et al reviewed data for 1000 patients who underwent bedside PCT over 10 years and found it to be a safe procedure with minimal complications, even for high-risk patients. [17]
Absolute contraindications are as follows:
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Patient age younger than 8 years
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The necessity of emergency airway access because of acute airway compromise
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Gross distortion of the neck anatomy due to the following:
Hematoma
Tumor
Thyromegaly (second or third degree)
High innominate artery
Relative contraindications are as follows:
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Patient obesity with a short neck that obscures neck landmarks
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Medically uncorrectable bleeding diatheses
Prothrombin time or activated partial thromboplastin time more than 1.5 times the reference range
Platelet count less than 50,000/µL
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Bleeding time longer than 10 minutes
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Need for positive end-expiratory pressure (PEEP) of more than 20 cm of water
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Evidence of infection in the soft tissues of the neck at the prospective surgical site
PCT is no longer considered absolutely contraindicated in patients with necks that are difficult to extend (eg, due to trauma or previous cervical fixation) or previous PCT. In fact, the previous site of PCT provides a reliable access site, and wound healing in the scar has not proven to be an issue. [3] Clinical judgment is used on a case-by-case basis to determine safety and feasibility.
Relevant Anatomy
A plexus of veins is found in the neck, including veins that drain the thyroid, the inferior laryngeal vein, and the anterior jugular vein. Although these veins are not visualized during PDT, it is necessary to know their approximate location and the inherent risk of bleeding should one of these vessels be injured. Given that the incision for PDT is small, there will be limitations to accessing the cut ends of bleeding vessels. Absorbable suture material should be available for vessel ligation.
Preoperative Workup
Laboratory Studies
These include the following:
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Complete blood count: Platelet count must be more than 50,000/µL
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Bleeding time: Check if blood urea nitrogen is more than 40 mg/dL or if the creatinine level is above 4 mg/dL; bleeding time must be less than 10 minutes
Imaging
A standard chest radiograph can provide information regarding the tracheal air column. Anteroposterior filtered tracheal views and lateral soft tissue views of the neck provide information regarding the glottic and subglottic air columns.
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Guidewire dilator forceps (GWDF).
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Rapitrach dilating forceps.
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Percutaneous dilatational tracheotomy (PDT technique). Needle access of airway after blunt dissection of pretracheal tissues.
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Percutaneous dilatational tracheotomy (PDT technique). After removing the needle and reaspirating to confirm catheter location in the airway, the guidewire is placed.
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Percutaneous dilatational tracheotomy (PDT technique). Serial dilations are performed over the guidewire.
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Percutaneous dilatational tracheotomy (PDT technique). A tracheostomy tube is inserted in the dilated passageway using a dilator as obturator over the guidewire.
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Guidewire dilating forceps (GWDF) technique. The guidewire dilator forceps are advanced along the Seldinger wire into the long axis of the trachea.
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Guidewire dilating forceps (GWDF) technique. The guidewire dilator forceps enlarge the hole between tracheal rings.
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Thin lines from top to bottom indicate thyroid cartilage, cricoid cartilage, first tracheal cartilage, second tracheal cartilage, and third tracheal cartilage. Arrows indicate access sites, optimally between the first and second tracheal rings or second and third tracheal rings. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Ciaglia Blue Rhino® kit; from left to right: FEP catheter introducer needle, J-tip guidewire (TFE-coated stainless steel) with safety ridge and guiding catheter, Ciaglia Blue Rhino® G2 advanced dilator (radio-opaque), and dilator assembly. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Ciaglia Blue Rhino® kit with multidilator kit. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Tracheostomy tube with loading dilator, deflated balloon. The tracheostomy tube should fit snugly on the dilator. Ensure that the balloon is completely deflated. Thoroughly lubricate the tracheostomy tube assembly. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Verify entrance into the tracheal lumen via aspiration on the syringe resulting in air bubble return. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Remove the FEP sheath or introducer needle while maintaining the position within the tracheal lumen. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Percutaneous dilatational tracheotomy (PDT) technique. Serial dilations are performed over the guidewire. To properly align the dilator on the guidewire/guiding catheter assembly, take care not to advance the Ciaglia Blue Rhino® G2 advanced dilator beyond the black, skin-level mark. This will prevent injury to the posterior tracheal wall. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Percutaneous dilatational tracheotomy (PDT) technique. A tracheostomy tube is inserted into the dilated passageway using a dilator as obturator over the guidewire. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Ideally, tube placement is made at the level between the first and second tracheal cartilages or between the second and third tracheal cartilages. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Puncture in the trachea is performed by directing the needle, in the midline, posterior and caudal. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Remove the FEP sheath or introducer needle while maintaining the wire guide position within the tracheal lumen. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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With the balloon fully deflated, advance the balloon catheter and tracheostomy tube assembly as a unit over the guidewire while maintaining the position of the distal wire guide marking at the skin level. Align the proximal end of the balloon catheter at the mark on the proximal portion of the wire guide. This will ensure the distal end of the balloon catheter is correctly aligned on the guidewire, preventing possible trauma to the posterior tracheal wall during subsequent manipulations. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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While maintaining the visual reference points and positioning relationships of the wire guide and balloon catheter assembly, inflate the balloon. To avoid balloon rupture, do not exceed 11 atm. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Advance the deflated balloon catheter/loading dilator/tracheostomy tube/wire guide assembly as a unit into the trachea. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
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Representative external anatomy in a thin patient. Note the location of internal structures and ideal access points.
