Percutaneous Tracheostomy

Percutaneous tracheostomy (“perc trach”) is a procedure that is routinely performed at the bedside on patients who require prolonged mechanical ventilation or airway control due to an upper airway obstruction or for pulmonary hygiene. This technique is contraindicated in emergent situations, nonintubated patients, pediatrics, and in patients with midline masses. Furthermore, additional optimization must be achieved in those with uncorrected coagulopathies or high ventilator requirements (PEEP, FiO2, etc.) prior to proceeding.

After appropriate consent has been obtained, I’ll place the intubated patient in the supine position with neck extension (often needing a shoulder roll), increase the FiO2 to 1.0, and deepen the sedation with rocuronium for immobility.

Next, I’ll identify the thyroid cartilage (“Adam’s Apple”), cricoid cartilage, cricothyroid membrane (CTM), and sternal notch. Furthermore, I’ll use ultrasound to note the surrounding vascular anatomy. I’ll infiltrate lidocaine with epinephrine ~ 2 cm above the sternal notch, and make a ~1.5 cm transverse incision with finger/forceps-assisted blunt dissection down to the trachea. In the interim, I’ll have an assistant pass a bronchoscope through the indwelling endotracheal tube (ETT) to maintain continuous, direct visualization of the airway.

Once I can feel the trachea, I’ll gently bounce my forceps (or use a laser pointer!) as the ETT is slowly withdrawn but not extubated to localize my point of entry between the 1st-2nd or 2nd-3rd tracheal rings. I’ll puncture the airway with the introducer needle (under bronchoscopic visualization), aspirate air for confirmation and pass my catheter into the airway. After removing the needle, I’ll pass the J guidewire down to the carina. Using the Seldinger technique, I’ll pass and remove the introducer dilator over the guidewire to initially dilate the tract. Then I’ll pass the guiding catheter with the safety ridge at skin level. After lubricating the main dilator with saline, I’ll advance it into the trachea over the guiding catheter/J-wire unit with gentle pressure until a loss of resistance is felt. I’ll gently pass and remove the dilator to help “open up” the tract a bit.

“Main” dilator

Then, I’ll pass a lubricated, deflated tracheostomy tube (“trach tube“) on the appropriately sized blue dilator over the guiding catheter/J-wire unit. I’ll then remove the dilator, guiding catheter, and J-wire. I’ll inflate the trach tube cuff, place the inner cannula and connect the ventilator circuit. After stabilizing the trach tube with ties and sutures, I’ll extubate the ETT and place the bronchoscope within the trach tube to suction out blood/secretions in the airway.

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