Percutaneous Dilatational Tracheostomy

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W15 Percutaneous Dilatational Tracheostomy

Cherisse Berry, Daniel R. Margulies

image Before Procedure

Indications

• Requirement of a temporary or long-term artificial airway for prolonged mechanical ventilation
• Management of secretions
• Nonemergency airway obstruction

Contraindications

• Relative contraindications:

• Inability to clearly palpate and identify tracheal landmarks
• Enlarged thyroid or other neck mass
• Active infection at the site
• Emergency need for airway
• Positive end-expiratory pressure (PEEP) greater than 20 cm H2O
• Previous tracheostomy
• Previous surgical scar
• Bleeding
• Increased intracranial pressure
• Clinically significant coagulopathy
• Documented tracheomalacia
• Cervical irradiation
• Morbid obesity
• Maxillofacial or neck trauma
• Lack of cervical spine clearance
• Inability to extend the neck because of cervical spine fracture
• In addition, we do not perform the procedure in patients younger than 16 years of age because of the scarcity of experience reported in pediatric patients.

Equipment

Equipment required at the bedside to perform the percutaneous dilatational tracheostomy (PDT) procedure should include:

• PDT introducer set (Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer Set #C-PTIS-100-HC, Cook Critical Care, Bloomington, Indiana)
• Bronchoscope with video monitor display and bronchoscopy endotracheal tube adapter
• Continuous electrocardiographic (ECG) monitor
• Blood pressure monitoring device
• Pulse oximeter
• Free-flowing intravenous catheter
• Mechanical ventilator
• Suction
• Resuscitation (“crash”) cart
• Open tracheostomy instrument tray (unopened)

Supplies required at the bedside include:

• Chloroprep or other solution for skin preparation
• 4 × 4-inch bandages
• Syringes and needles
• Sterile gowns and gloves
• Shiley Percutaneous Dual Cannula Cuffed Tracheostomy tube
• Kelly clamp
• Sterile saline solution

Medications required at the bedside include:

• 1% Xylocaine with epinephrine 1 : 100,000
• Midazolam, 1 mg/mL injectable or other appropriate sedative
• Morphine, 10 mg injectable or other appropriate narcotic
• Vecuronium, injectable or other appropriate paralyzing agent
• Sterile normal saline flush solution
• Other medications at the discretion of the PDT operator
• The choice of a PDT introducer set may vary by institution; ours includes the set listed only because we have significant experience with it. However, it is critical that only one type of PDT introducer set be in use in an institution at any given time. To ensure maximum safety, every aspect of this procedure must be standardized, especially the equipment used.

image Anatomy

The thyroid notch and cartilage are palpated, followed by the cricothyroid membrane and cartilage and the tracheal rings. It is essential that the tracheal puncture be made inferior to the cricoid cartilage landmark. If the second and third tracheal rings cannot be distinctly identified, the procedure is aborted, and an open tracheostomy is performed.

image Procedure

• A single tapered PDT dilator and kit with simultaneous intraoperative bronchoscopy is used.
• Two teams are used simultaneously. One team manages the endotracheal tube, and the other manages the placement of the tracheostomy tube.
• The patient’s physiologic parameters, including arterial oxygen saturation, are monitored continuously throughout the procedure by the intensive care unit (ICU) nurses and respiratory therapist.
• Intravenous sedation and paralytic agents are administered as required, and the patient is fully ventilated via an endotracheal tube.
• The patient is positioned with the neck slightly extended and a pillow under the shoulders.
• Under sterile conditions, the PDT dilators and tracheostomy tube must be prepared.

• The Blue Rhino tracheal dilator is water activated, so it is dipped in sterile saline or water to enhance its lubricant coating.
• The Shiley Percutaneous Dual Cannula Cuffed Tracheostomy Tube is designed specifically to be used with the Cook Percutaneous Tracheostomy Introducer Set. Depending on the size of the patient, it is prepared by inflating the balloon to ensure integrity and then collapsing the balloon by withdrawing all air.
• The tracheostomy tube, with the cuff completely deflated, is inserted over the introducer dilator as one unit, placed 2 cm from the tip of the dilator and then lubricated with sterile gel. The Shiley’s tapered distal tip and inverted cuff shoulder are specifically designed for easier insertion. It is important that the tracheostomy tube be placed exactly 2 cm from the tip. If it is placed more than 2 cm from the tip, it will likely not enter the trachea. If it is advanced too far and placed less than 2 cm from the tip, the trachea may be damaged upon insertion.

• The neck is prepared with Chloroprep.
• The dermis and subcutaneous tissues are infiltrated with 1% lidocaine with epinephrine.
• The upper airway endoscopist will then introduce the bronchoscope into the endotracheal tube.
• The endotracheal tube is untaped, the cuff deflated, and the tube is then withdrawn until the tip lies just below the vocal cords. The utmost care is taken to avoid withdrawing the endotracheal tube too far, which could result in extubation of the patient. We recommend that the bronchoscope remain near the tip of the endotracheal tube but entirely within it to prevent inadvertent puncture or spearing of the bronchoscope by the puncture needle.
• The PDT operator verifies the patient’s neck anatomy, starting with palpation of the thyroid notch and cartilage, then moving down to the cricothyroid membrane and cartilage and the tracheal rings.
• The anatomy is reconfirmed with digital palpation of the cricoid cartilage, because it is essential that the tracheal puncture be made inferior to this landmark. If the second and third tracheal rings cannot be distinctly identified, the procedure is aborted, and an open tracheostomy is performed.
• A 2-cm horizontal skin incision centered between the second and third tracheal rings is made, and the midline subcutaneous tissues are dissected bluntly with a hemostat until the pretracheal fascia is exposed.
• The PDT operator reconfirms the tracheal anatomy by direct palpation through the incision. The trachea is then punctured between the second and third tracheal rings with a 14-gauge cannula-over-needle from the PDT kit.
• Tracheal penetration is confirmed by visualization with the bronchoscope as well as aspiration of air from the needle.
• The needle is removed and a J-tip guidewire is then introduced into the trachea through the cannula and visualized with the bronchoscope. The puncture cannula is then withdrawn.
• A small 14F dilator is then introduced over the guidewire to widen the tracheal opening. The dilator is then withdrawn.
• An 8F guiding catheter is introduced over the guidewire to the skin level mark on the guidewire. The guiding catheter and guidewire are introduced as a unit into the trachea until the safety ridge on the guiding catheter is at the level of the skin. Positioning of the guiding catheter is confirmed by aligning the proximal end of the catheter with the proximal gray mark on the guidewire. This positioning is critical to prevent displacement of the J-tip guidewire and possible trauma to the posterior tracheal wall during subsequent dilatations.
• The lubricated Blue Rhino tracheal dilator is then passed over the cannula and guidewire and into the trachea to fully dilate the tract. This requires forceful pressure to accomplish smoothly.
• The tracheal dilator is then withdrawn, but the guiding catheter and guidewire remain in place.
• The tracheostomy tube and introducer dilator are threaded over the guide cannula and guidewire as one unit and inserted into the trachea under direct bronchoscopic visualization.
• The introducer dilator, guiding catheter, and guidewire are then withdrawn, leaving the tracheostomy tube in place.
• The inner cannula is then inserted, and the cuff is inflated.
• The PDT operator continues to hold the tracheostomy in place with one hand and never removes it until the tracheostomy tube is sutured in all four corners to ensure the tube is not inadvertently displaced.
• The bronchoscope is then inserted into the tracheostomy tube to confirm placement within the trachea.
• The ventilator tubing is then connected to the tracheostomy. Appropriate tidal volume and oxygen saturation are confirmed.
• The tracheostomy tube is sutured to the neck with 4-0 gauge nylon sutures placed in each corner.
• Once the tracheostomy tube is sutured in all four corners and also secured around the neck with umbilical tape, the endotracheal tube is removed. Make sure that the umbilical tape is not placed too tightly, as skin breakdown can result. At least one finger should be able to fit between the umbilical tape and the skin.

image After Procedure

Postprocedure Care

• A simple 4 × 4-inch gauze dressing is partially slit and placed between the tracheostomy wings and the skin.
• A chest radiograph is optional.
• Close observation by the nursing staff is required to detect bleeding externally at the tracheostomy site or internally into the airway. Bleeding must be immediately reported to the PDT operator and ICU physician and must be carefully evaluated and controlled.
• Bleeding into the airway can lead to formation of an obstructing clot at the carina, with fatal consequences.

Complications

• Common:

• Bleeding
• Subcutaneous emphysema
• Extratracheal cannulation
• Brief episodes of hypoxia
• Stomal infections

• Serious complications:

• Puncture or laceration of the posterior tracheal wall
• Loss of airway
• Conversion to open tracheostomy
• Serious hemorrhage due to severed blood vessel
• Death

image Outcomes and Evidence

• PDT is a safe procedure, with morbidity and mortality rates equivalent to or lower than those of open tracheostomy.

• Numerous early studies reported the morbidity of PDT to be between 3% and 19%, compared with a complication rate of 26% to 63% for open tracheostomy.
• Recent studies have found the overall mortality for tracheostomy to be 37%, with no statistically significant difference in mortality for PDT compared with open tracheostomy.

• The incidence of wound infection has been reported to be 6.6%.

• One study compared PDT to surgical tracheotomy (ST) and found that PDT was associated with a significantly reduced risk of wound infection (OR, 0.28; 95% CI, 0.16-0.49; P < 0.0005).

• One report found the overall incidence of bleeding to be 5.7%, with no significant difference in incidence when comparing PDT to ST.

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