1. PERCUTANEOUS
TRACHEOSTOMY
SAJA ALDULAIJAN

2. Tracheostomy is a common surgical
procedure performed on critically ill
intensive care patients.
procedures are rapidly transforming many
areas of surgical practice. Percutaneous
tracheostomy, a minimally invasive
alternative to conventional tracheostomy.

3. Two new methods suitable for elective percutaneous
tracheostomy at the bedside have been introduced
based on the Seldinger technique.
The Ciaglia method, developed by Ciaglia et al in
1985, uses graded dilators and is currently the most
popular method.
Another technique, described by Griggs et al in 1990, is
a one-stage dilation technique using a modified
Howard-Kelly forceps as the tracheal dilator.

4. Percutaneous tracheostomy can
be performed by an anaesthetist
at the bedside in a controlled
setting (ICU) with the assistance
of nursing personnel without the
need to transfer the critically ill
patient to the operating theatre.

5. INDICATIONS FOR TRACHEOSTOMY
1.
2.
3.
4.
5.
Facilitate weaning from positive pressure
ventilation and sedation
Bypass an obstruction of the upper respiratory
tract.
Prevent aspiration from the pharynx or
gastrointestinal tract.
Facilitate removal of secretion by aspiration.
Facilitate long-term airway management

6. Why percutaneous tracheostomy not
open surgical tracheostomy
 It is a relatively simple technique suitable for trained
staff in the critical care setting.
 It does not require an operating theatre and the
procedure is usually performed under local
anaesthetic, sedation and neuromuscular blockade
as appropriate.
 Forms a stoma between tracheal rings, resulting in
reduced blood loss as there is usually no disruption
of blood vessels. Moreover, the tracheostomy tube is
fitted snugly in the stoma thereby minimising any
tendency to bleeding after the procedure.

7.  Infection rates for percutaneous tracheostomy range
from 0 to 3.3%, whereas those for open
tracheostomy have been reported to be as high as
36%.
 Stenosis rates for percutaneous tracheostomy range
from 0 to 9%. The reported incidence of late
complications resulting from open tracheostomy
such as tracheal stenosis, tracheomalacia, fistula and
scarring varies widely.
 Small and neat stoma of dilatational tracheostomy
generally results in a more cosmetic scar.

8. Conditions in which surgical tracheostomy may be
safer than percutaneous tracheostomy:
 Emergency tracheostomy tube placement
 Difficult to palpate the anatomical landmarks:





very obese patients
short or bull neck
enlarged thyroid
nonpalpable cricoid cartilage
gross deviation of trachea
 Infection at or near the intended site for tracheostomy.
 In paediatric age group (controversial). Children have a
more compliant trachea than adults leading to a
tendency to collapse when pressure is exerted with
dilators.

9.  Previous neck surgery may distort the anatomy.
 In unstable cervical spine fracture.
 Required PEEP > 15 cm H 2 O, as oxygenation may
becompromised during the procedure.
 Malignancy at the site of tracheostomy.
 Uncontrolled coagulopathy, considered as a relative
contraindication

10. DESCRIPTION OF
TECHNIQUES

11. Equipment
 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 :
1.
2.
3.
4.
5.
6.
7.
Sterile field & cleaning fluid
Lubricating jelly (plenty of)
Local anaesthetic with adrenaline
Tracheal dilator
Fibreoptic laryngoscope/bronchoscope
Catheter mount to accept scope
Intravenous anaesthesia

13. Airway Management
 Although inhalation anaesthesia is possible, a total
intravenous technique provides much smoother
anaesthesia and better conditions for performing the
bronchoscopy and tracheostomy. Full monitoring is
instituted, and ventilatory parameters altered during
the bronchoscopy to maintain adequate oxygenation
and end-tidal CO2 levels.

14.  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

16. Landmarks
 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 in the picture at left.
 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.

18. Seldinger Method
 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.

20. Dilation
 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.

22. Tube placement
 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.

24. Finished
 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.

26. COMPLICATIONS OF INSERTION
 During the procedure, the patient may develop hypoxia due to
failure of ventilation. Furthermore, ventilation of the patient may
also be difficult if the cuff of the endotracheal tube is
inadvertently punctured. If any difficulties are encountered on
insertion of the tracheostomy tube, the existing endotracheal
tube should be advanced beyond the incision in the trachea and
ventilation recommenced until the patient is stable enough to
resume the procedure.
 The patient may develop pneumothorax, pneumomediastinum
or creation of a false passage and subcutaneous emphysema due
to the placement of the tracheostomy tube in the paratracheal
space.
 Damage or injury to the posterior tracheal wall may lead to
tracheo-oesophageal fistula.

27.  Major bleeding is unusual. Minor bleeding can usually be
controlled by pressure or occasionally a suture. Haemorrhage
into the airway is potentially dangerous as it may result in a
blood clot obstructing the airway.
 Needle puncture on the lateral wall of trachea may subsequently
lead to stenosis. 21
 Dislodgement of the tracheostomy tube soon after the procedure
may be hazardous as the entry to the trachea is small and
deep, hence replacement of the tube may be impossible. The
percutaneous tracheostomy tube should not be pushed blindly
back in but replaced after proper dilation of the track following
orotracheal reintubation.
 Secondary haemorrhage may occur either from infection or
erosion of vessels.