Seminar on Tracheostomy

1. TRACHEOSTOMY

2. CONTENTS
• Introduction
• History
• Indications
• Contraindications
• Surgical Anatomy
• Armamentarium
• Types
• Techniques
• Post operative Care
• Complications

3. Introduction
• Trachea is a conduit between the upper airway and the lungs.
• It delivers moist warm air, expels CO2 and secretions from the
respiratory system.
• Blockage at any point along this conduit can be fatal.
• Surgical creation of an opening into the trachea is the principle way
of securing the airway.

4. • TRACHEOTOMY
Surgical procedure in which an opening is made in the anterior wall of the
trachea to establish an airway.
Often temporary and reversible
- Heister, 1718
TRACHEOSTOMY
Surgical creation of an opening into the trachea through the neck with the
trachea being brought into continuity with the skin.
Most often, not always permanent
- Negus, 1938

5. History
Oldest surgical procedure - first mentioned in Rig
Veda in 2000 B.C. and in Egyptian manuscripts
dating back to 3500 years.
Galen, Aretaeus and Antyllus (around 2nd century)
- provided descriptions of elective tracheostomy
Hieronymus Fabricius (1617) and Habicot (1620):
First technical descriptions of the surgical
procedure.
1718 - Heister introduced the term “tracheotomy”.

6. Chevalier Jackson, 1921, advocated a
low tracheotomy in second and third
tracheal rings as opposed to a high
tracheotomy (cricothyrotomy).
Bretonneau and Trousseau, 1833, published
about treating airway obstruction in children
resulting from croup or diphtheria. Thus,
tracheostomy became acceptable.

7. Indications
1. Major laryngeal trauma
2. Inability to intubate or perform needle cricothyrotomy in pediatric patient
3. Any patient that is adequately stable, and who requires a surgical airway
that can be placed in a controlled fashion in the operating room
4. Laryngeal foreign body or pathology (e.g., tumor) prohibiting
cricothyrotomy
5. Prolonged ventilation
6. Facilitation of management of cervical spine injury or oncologic resection
of head and neck
Fonseca, Walker. Oral and maxillofacial trauma, 4th edition

8. Indications
Relative Indications:
Multiple maxillofacial injuries treated with IMF
A semiconscious and unco-operative patient after a head injury
A patient requiring multiple visits (involving anaesthesia) to theatre for orthopedic or
perhaps skin grafting procedures.
Absolute Indications:
When injuries are severe enough to cause hypercarbia and/or hypoxemia from the
outset, - flail chest, lung contusion or aspiration, ARDS (shock lung) or fat embolism.
For control of cerebral oedema (by controlling blood gases) in severe head injuries.
Where sputum retention is a problem - either as a result of pre-existing lung disease
(smoking) or as a result of secondary infectipn to facilitate adequate tracheobronchial
toilet.
Rowe and Williams’ Maxillofacial Injuries, 2nd Edition, Vol. 1

9. Contraindications
• Emergency tracheostomy is contraindicated if the patient’s airway can be
safely secured by other means ( e.g., rescue airway, rapid sequence
intubation (RSI), needle or open cricothyrotomy)
• Avoid performing tracheostomy through an expanding hematoma.

10. ANATOMY AND EMBRYOLOGY OF
TRACHEA

11. EMBRYOLOGY
• At 25 days gestation, the respiratory diverticulum
originates between the IV and VI pharyngeal arches
(V is rudimentary) at the laryngotracheal orifice from
what becomes the esophagus in the original foregut.
• The esophagotracheal ridge eventually fuses
together and forms the esophagotracheal septum.
• The proximal portion of the respiratory diverticulum
forms the larynx and starts to branch at 4th week of
gestation to form the right and left main bronchi.
• This continues to divide until approximately 8 years
of age.

12. Surgical Anatomy
Trachea - cartilaginous tubular structure connecting the
larynx superiorly and the main bronchi inferiorly.
Lower edge of the cricoid cartilage defines the beginning
of the trachea.
It begins at the level of C6 vertebra in continuity with the
larynx - attached to the lower margin of cricoid cartilage
by the cricotracheal ligament.
Structure of Trachea (Anterior view)
Furlow PW, Mathisen DJ. Surgical anatomy of the trachea. Ann Cardiothorac Surg 2018;7(2):255-260.

13. The end of the trachea is marked by the carina.
The carina is usually found at the level of the T4
vertebral body. Its vertical position in the mediastinum
changes with the phases of respiration.
On average,
 Length: 11.8 (nomal range 10-13 cm in males;
tends to be shorter in females)
18 to 22 D-shaped rings - anterior and lateral walls
made of C-shaped cartilage and posterior
membranous wall connecting the arms of the C.
Furlow PW, Mathisen DJ. Surgical anatomy of the trachea. Ann Cardiothorac Surg 2018;7(2):255-260.

14. There are approximately 2 rings of cartilage per cm of trachea.
Each tracheal ring is an average of 4mm in height.
The wall of trachea - about 3mm in thickness.
Average external diameter of trachea: 2.3cm coronal dimension and 1.8cm sagittal
dimension
Shape:
 At birth: C.S. shape of lumen of trachea is circular
 In an adult: Ovoid form (circular may persist)
Luminal diameter of the trachea varies with alterations in intraluminal pressure
occuring during norma respiration, ventilation and Valsalva maneuvers.

15.  Coughing narrows the lumen by ausing the trachealis muscle of the
posterior wall to pull the cartilaginous C-arms together.
 With age or due to obstructive airway disease,the lateral diameter of the
lumen tends to narrow, while the anteroposterior diameter increases
resulting in “saber sheath” trachea.

16. BLOOD SUPPLY
• The arteries supplying the trachea approach
the tracheal wall laterally and vascularize the
trachea in a segmental fashion along its
longitudinal access.
• This segmental arrangement of blood flow
limits circumferential tracheal dissection to no
more than 1–2 cm on either side of a tracheal
anastomosis due to the risk of
devascularization and ischemia with larger
dissections.

17. BLOOD SUPPLY...
• The arterial supply of the trachea
divides it into the upper (cervical) and
lower (thoracic) trachea.
• The tracheoesophageal branches of
the inferior thyroid arteries bring
blood to the cervical trachea from the
right and left thyrocervical trunks that
branch off the subclavian arteries.

18. BLOOD SUPPLY...
• The first tracheoesophageal branch supplies the
lower cervical trachea,
• The second branch supplies the middle cervical
trachea and
• The third branch supplies the upper cervical
trachea.
• The superior thyroid artery forms an anastomosis
with the inferior thyroid artery where fine
branches supply the thyroid isthmus and the
adjacent anterior tracheal wall.
• The thoracic trachea and carina receive blood from
the bronchial arteries arising directly from the
aorta.

19. Lymphatic Drainage
• Lymphatic drainage of the trachea is made up of pretracheal and
paratracheal nodes.

20. NERVE SUPPLY
• Vagus through recurrent laryngeal nerve (parasympathetic nerves) - sensory
and secretomotor to the mucous membrane, and motor to trachealis muscle.
• Sympathetic nerves from the cervial ganglion are vasomotor.

21. STRUCTURAL RELATIONSHIP
Critical mediastinal structures surrounding the trachea.
Large vessels intimately associated with the trachea.
Right oblique view
ANTERIOR:
• Isthmus of the thyroid gland covering
the 2nd and 3rd tracheal rings.
• Inferior thyroid veins below the
isthmus.
• Pretracheal fascia enclosing the thyroid
and the inferior thyroid veins.
• Sternohyoid and sternothyroid muscles
• Investing layer of the deep cervival
fascia and the suprasternal space.
• The skin and superficial fascia.

22. STRUCTURAL RELATIONSHIP...
POSTERIOR:
• Oesophagus
• Longus colli
• Recurrent laryngeal nerve in the
tracheoesophageal groove.
On Each Side:
• The corresponding lobes of the
thyroid gland.
• The common carotid artery
within the carotid sheath.

23. STRUCTURAL RELATIONSHIP...
The Oesophagus:
• has an intimate relationship with the trachea
along its course.
• begins at the level of cricoid cartilage.
• runs toward the gastroesophageal junction
along the left posterior border of the trachea.
The Vagus:
The right and left vagus nerves travel distally
through the neck in a position posterolateral to
the corresponding common carotid arteries.

24. STRUCTURAL RELATIONSHIP...
• The Brachiocephalic artery
• The Left Common Carotid artery
• The Superior Vena Cava
• The Azygos vein
• The Pulmonary trunk

25. Suprasternal Space of Burns
Contents:
• Sternal head of the
sternocleidomastoid muscle.
• Anterior jugular vein anastomoses
• Lymph nodes - part of level VI
• Interclavicular ligament

26. ARMAMENTARIUM
Tracheostomy Set
A tracheostomy set consists of:
• Tracheostomy tube
• Sharp hook
• Blunt hook
• Tracheal dilator

27. TRACHEOSTOMY TUBE
• Also called Jackson’s tube.
• Curved tube which is inserted into the surgical opening made in the
trachea for airway management.
• Main Function: To allow air/oxygen entry through a tracheostomy wound.
• Classification:
Metallic or Non-metallic (Portex)
Reusable or Disposable
With cuff or Without cuff

28. PARTS OF A TRACHEOSTOMY TUBE
A tracheostomy tube consists of three
parts:
• Outer cannula with flange (neck plate)
• Inner cannula
• Obturator

29. TYPES OF TRACHEOSTOMY TUBES
• Silver/Metal tubes
eg., Jackson’s tube, Fuller’s tube
• Plastic tubes:
- most commonly used.
- Flexible and less traumatic.
e.g., Romsons tubes, Portex tubes,
Shiley tubes.
• Polyvinylchloride (PVC) tubes
• Silastic tubes
Shiley
Portex
Jackson’s tube
Fuller’s

30. TYPES OF TRACHEOSTOMY TUBES
Cuffed Tube with Disposable Inner Cannula
• Indication: Used to obtain a closed circuit for ventilation
• Recommendation:
• Cuff should be inflated when using with ventilators.
• Cuff should be inflated just enough to allow minimal
airleak.
• Cuff should be deflated if patient uses a speaking
valve.
• Cuff pressure should be checked twice a day.
• Inner cannula is disposable.
Cuffed Tube with Reusable Inner Cannula
Used to obtain a closed circuit for ventilation
Inner cannula is not disposable. It can be reused
after cleaning it thoroughly.

31. Cuffless Tube with Disposable Inner Cannula
Indications:
• Used for patients with tracheal problems
• Used for patients who are ready for
decannulation
Inner cannula is disposable.
Cuffless Tube with Reusable Inner Cannula
Inner cannula is not disposable. It can
reused after cleaning it thoroughly.

32. Fenestrated Cuffed Tracheostomy Tube
Indication: Used for patients who are on the ventilator
but are not able to tolerate a speaking valve to speak.
• There is a high risk for granuloma formation at the site
of the fenestration (hole).
• There is a higher risk for aspirating secretions.
• It may be difficult to ventilate the patient adequately.
Fenestrated Cuffless Tracheostomy Tube
Indication: Used for patients who have difficulty using a
speaking valve.
There is a high risk for granuloma formation at the site of
the fenestration (hole).

33. Indications for a cuffed tracheostomy tube include the following:
• Risk of aspiration
• Newly formed stoma in adult
• Positive-pressure ventilation
• Bleeding (eg, in a multiple-trauma patient)
• Unstable condition
Contraindications for a cuffed tracheostomy include the following:
• Children younger than 12 years
• Significant risk of tracheal tissue damage from cuff
Indications for an uncuffed tracheostomy tube include the following:
• Stable stoma Pediatric and neonatal patients
• Upper-airway obstruction due to tumors or neuromuscular disorders causing vocal
cord palsy
Contraindications for an uncuffed tracheostomy include the following:
• Dependent on positive-pressure ventilation
• Significant risk of aspiration Newly formed tracheostomy

34. Metal Tracheostomy Tube
Cannot be left in position for
more than 48 hours

35. Sharp Hook:
• Used for stabilizing the trachea, while making a stab wound,
as the trachea tends to move up and down rapidly during
repiratory obstruction.
• It is inserted just below the cricoid cartilage.
Blunt Hook:
• Used for retracting the isthmus of the thyroid upwards while
performing tracheostomy.
Tracheal Dilator:
• Meant for dilation of the stab incision given over the trachea
to facilitate introduction of the tracheostomy tube.
• The blades of the instrument are opened when the handles
are brought together.

36. TUBE SELECTION
• An appropriate tracheostomy tube is selected to occupy two thirds to
three quarters of the tracheal lumen diameter.
• No. 7 or 8 Shiley tube : for adult males.
• No. 5 or 6 : for adult females
• 2.5-5.5 mm in internal diameter and lengths ranging from 30-36 mm
for neonates and 39-56 mm for pediatric patients.
• For pediatric patients: internal diameter - 2.5 to 5.5 mm
length - 30-36 mm for neonates
- 39-56 mm for pediatric patients

37. TYPES OF TRACHEOSTOMY
Emergency:
• It is employed when airway obstruction is complete or almost complete.
• There is an urgent need to establish the airway.
• Intubation or laryngotomy are either not possible or feasible in such cases.
Elective/Tranuquil:
• This is a planned, unhurried procedure.
• Almost all operative surgical facilities are available, endotracheal tube can be put and local or general
anaesthesia can be given.
• It is of two types:
(a) Therapeutic: to relieve respiratory obstruction, remove tracheobronchial secretions or give assisted
ventilation.
(b) Prophylactic: to guard against anticipated respiratory obstruction or aspiration of blood or pharyngeal
secretions such as in extensive surgery of tongue, floor of mouth, mandibular resection or laryngofissure.

38. • Permanent: Required for case of bilateral
abductor paralysis or laryngeal stenosis.
BASED ON LEVEL TRACHEOSTOMY:
• High:
• in the 1st and 2nd tracheal rings above the isthmus
of the thyroid gland.
• perichondritis of the cricoid cartilage and
subglottic stenosis and is always avoided.
• Only indication - carcinoma of larynx because in
such cases, total larynx anyway would ultimately
be removed and a fresh tracheostome made in a
clean area lower down.

39. Middle:
• in the 3rd and 4th trachea rings behind the
isthmus (operation of choice)
• would entail division of the thyroid isthmus or
its retraction upwards or downwards to expose
this part of trachea.
Low
• in the 5th and 6th rings below the level of
isthmus
• Trachea is deep at this level and close to several
large vessels
• also there are difficulties with tracheostomy
tube which impinges on suprasternal notch.

40. TECHNIQUES OF
TRACHEOSTOMY

41. OPEN TRACHEOSTOMY
PROCEDURE:
Marking of Incision:
• The skin incision is marked with the patient in a normal head position.
• This precaution is to ensure that the incision is located over the planned tracheal opening
and to prevent irritation of the skin, dislodgement of the tube, or tension of the skin
against the tube.

42. Patient Position:
• The patient is positioned supine with a bolster
placed transversely behind the shoulders to extend
the neck.
• This position provides maximal exposure for the
surgical site.
• Movement of the neck should be attempted only if
cervical spine injury has been excluded.
Anaesthesia:
• Local anaesthesia with a vasoconstrictor is
infiltrated into the skin and deeper neck tissues to
reduce the amount of bleeding and provide
analgesia during the procedure with the patient
awake.

43. Incision:
• Both vertical and horizontal incisions
can be advocated.
Vertical Incision:
• In emergency situation
• to maintain midline dissection
• to reduce the potential for anatomic
damage when the direction of the
incision is changed.
Horizontal incision:
• much preferred in elective
tracheostomy for improved cosmetic
results.

44. •A 4- to 5-cm incision is made
approximately 2cm below the cricoid
cartilage.
•The incision is carried through
subcutaneous tissue and platysma
muscle until the superficial layer of the
deep cervical fascia is identified.

45. Two principles must be followed to enter into the trachea:
• The cricoid cartilage and 1st tracheal ring must not be cut or injured.
• The incision into the trachea must not extend below the fourth tracheal ring.
• A tracheostomy hook is placed between the 1st and the 2nd tracheal rings.
• Gentle superior traction is used to elevate the trachea into the surgical field.
• A traction suture of 2-0 silk is placed through the tip of the flap and through the inferior
margin of skin and is tied.
• This positions the flap tip downward and forward.

46. • A Trousseau dilator or a Kelly hemostat is inserted and spread vertically.
• The tracheal lumen should be visualized.
• If an endotracheal tube is present, the tube should be visible.
• With the Trousseau dilator in place, the tracheostomy tube is inserted under direct vision.
• Once the tube is in place and before cuff inflation, the lung fields should be auscultated
and chest movement observed

47. Skin Closure:
• The skin should be loosely sutured or left open.
• Skin closure that is too tight results in subcutaneous emphysema by not allowing air
to escape during forced expiration or continuous positive-pressure ventilation.
• A tracheostomy gauze dressing should be placed under the tracheostomy tube
phalanges and around the cannula.
• To prevent inadvertent extubation, the tube should be secured with cloth tape tied
around the patient's neck.
• Finally a chest x-ray should be obtained to evaluate tube placement and to check for
pneumothorax, a complication of special concern in the pediatric population.

49. The inverted U incision described by Bjork and Dukes offers the following advantages:
• it prevents the cannula from being inserted anterior to the trachea,
• the patient can breathe more easily through the stoma if the cannula is lost in the first few days
• changing of the cannula is facilitated
Various entrance incisions into the trachea (U, inverted U, T, and cruciform) have been
advocated.

50. Pediatric Anatomical Considerations
• Dome of the pleura extends into the neck and is vulnerable to injury.
• The hyoid bone, thyroid cartilage and cricoid cartilage lie higher in the neck.
• Trachea is pliable and difficult to palpate.
• Due to short neck in children, the left brachiocephalic vein may come up above the
suprasternal notch. Therefore the dissection is rather difficult.
• Also, child’s trachea is softer and more mobile than the adult’s, therefore not so
readily identified and isolated.
• Its softeness means that care must be taken in incising the child’s trachea, not to
let the scalpel plunge through and damage the underlying oesohagus

51. Pediatric Tracheostomy
Tube selection:
Wetmore recommends the following pediatric
tracheostomy tube sizes, determined on the basis
of patient age and weight :
• Premature neonates or babies who weigh less
than 1000 g - 2.5 mm
• Babies who weigh 1000-2500 g - 3 mm
• Neonates aged 0-6 months – 3-3.5 mm
• Infants aged 6 months to 1 year - 3.5-4 mm
• Infants aged 1-2 years – 4-4.5 mm
• Children older than 2 years – (age [years] + 16)/4

52. Considerations during the procedure:
• Bronchoscope or ETT inserted to provide
rigidity to the trachea
• Positioning: neck extended with a
shoulder roll, and the head is stabilized
with a ring under the occiput.
• A vertical incision is used.
• Before the anterior tracheal wall is incised,
retraction sutures are placed in either side
of the midline.
• Routine post-op neck and chest
radiograph taken.

53. Postoperative Care
• Occlusion of the tracheal cannula from mucus plugs or hemorrhage may occur,
with dire consequences if not corrected.
• Particular attention should be paid to the cuff pressure, which should be
maintained at 20 mm Hg.
• With the loss of the body's ability to humidity inspired air because of bypassing the
nasopharynx, humidified air (at 40%) is required at all times to prevent mucosal
drying and to facilitate removal of secretions.
• Decreased humidification leads to dehydration, resulting in secretions becoming
more viscous and therefore more difficult to expel.

54. Suctioning:
• "Trach care" mandates that the
tracheostomy tube be aspirated
frequently with the use of sterile
techniques to remove mucus, blood,
and secretions.
• Trach care should be performed every
hour for the first 2 days, every 2 hours for
the next 2 days, and every 4 hours
thereafter.

55. • The surgical wound should be protected with sterile
gauze dressings, changed frequently to keep it
clean and dry.
• Tracheostomy reduces the effectiveness of the
cough mechanism.
• A weak cough predisposes the patient to
aspiration.

56. Care of the Tube:
• Fresh tracheostomy should be left in place for 3-5 days for the permanent tract to
form.
• a tube in infant should not be changed for the first time without a bronchoscope
readily available.
Care of Cuffed Tube:
• Inflate:
• immediately post-op
• during mechanical ventilation
• Deflate:
• Cuff should be deflated atleast 5 mins every hour.

57. Changing the Tracheostomy Tube
Maintain the neck in the same position
(slightly extended) for removal and
insertion so that the tract is not lost.
If the tube is already out, and the
specifics of the tract are unknown,
extending the neck to align the stoma
with the tissue tract is the first best
position for tube replacement.

58. COMPLICATIONS
Immediate Complications:
• Hemorrhage
• Structural damage to trachea
• Air embolism
• Aspiration event
Early Complications:
• Tube displacement
• Surgical emphysema
• Pneumothorax/pneumomediastinum
• Stomal Infection/ulceration
• Dysphagia
Late complications:
• Tracheal stenosis
• Tracheomalacia
• Tracheoarterial fistula
• Tracheoesophageal fistula
• Aspiration

59. Hemorrhage:
• Haemorrhage may occur during the operation but more frequently is delayed.
• A medium sized vessel may be transected during the tracheostomy when the
patient is hypotensive and go unrecognised.
• Later when normotensive levels return brisk bleeding with aspiration may result.
• These skin bleeders are usually controlled by careful cautery or packing
petrolatum jelly gauze around the tracheostomy tube on the skin edges.
• Late haemorrhage is caused by the tip of tracheostomy tube eroding through the
walls of the trachea and a major vessel.
• The innominate artery is almost always involved occasionally the right common
carotid is involved.
Mehta AK, Chamyal PC. TRACHEOSTOMY COMPLICATIONS AND THEIR MANAGEMENT. Med J Armed Forces India. 1999;55(3):197-200.

60. Air Embolism:
• Caused due to air sucked into an inadvertently opened large neck vessel.
Displaced tube:
• This occurs if the tracheostomy is too low or not in the midline.
• When this complication occurs a very careful rapid reexploration of the wound must be
made, the edges of the trachea spread and the tube carefully reinserted.
Pneumothorax:
• This is due to the pleural domes in children lying higher in the neck and are therefore more
prone to injury.
• Another cause is pneumomediastinum, leading to ruptured pleurae and pneumothorax.
• This is thought to occur from air being sucked through the tracheostomy wound and is
more common in children due to the loose tissue in their necks.
• Minimal dissection of the pretracheal fascia is thought to lessen this complication.

61. Subcutaneous Emphysema
• Due to extensive dissection in the wound or closing the incision too tightly. Expired air, escaping
from the trachea under the skin tightly closed may dissect through the sub cutaneous tissue into
the neck or through the pretracheal fascia into the mediastinum.
• This is resolved spontaneously by releasing the skin sutures.
Aspiration
The easy access to the lower respiratory tract by the tracheostomy can allow the entry of unwanted
foreign materials.
More commonly presence of the tracheostomy tube leads to swallowing problems with the
resultant aspiration of food.
Presence of a cuff on the tracheostomy tube which can be inflated at meal time will prevent the
food entering the lungs but the inflated cuff sometimes increases the dysphagia.
Changing tube size and shape is sometimes helpful.

62. Tracheal stenosis
• Due to increased use of the cuffed tracheostomy tube for
assisted respiration.
• Onset of symptoms may vary between days to months after
decannulation.
• Treatment of tracheal stenosis may be conservative with
dilatation or surgical with resection of the stenotic portion.
• To prevent trachal stenosis one should avoid opening the
trachea above the second ring, avoid excessive removal of the
anterior wall or create an anterior tracheal flap.
• Inflate the cuff with right pressure and replace the cuffed tube
with a noncuffed tube when the respirator is no longer needed.

63. Tracheo-Oseophageal fistula
• The patient developes violent cough while eating,
leading to suspicion of tracheoesophageal fistula.
• Fistula may be early, secondary to incising the posterior
tracheal and anterior esophageal walls or late due to
erosion.
• The former can be prevented by making the tracheal
incision with a sickle shaped 12 blade.
• Late fistulas are usually the sequelae of prolonged
endotracheal intubation with an inflated cuff.
• The immediate treatment is to pass a longer cuffed tube
beyond the level of the fistula.
• Surgical correction consists of separating the esophagus
from the trachea and closure of both defects.

64. PERCUTANEOUS DILATIONAL
TRACHEOSTOMY (PDT)
• This technique was developed based on Seldinger's description of
arterial catheterization in 1953.
• Shelden in 1957, described a needle-guided trocar for access into the
trachea.
• Ciaglia et al described in 1985 a percutaneous dilational
tracheostomy (PDT) based on the Seldinger technique, using
sequential dilators of increasing diameter.
• Griggs et al in 1990, described a one stage dilation technique using a
modified Howard-Kelly forceps as the tracheal dilator.

65. Percutaneous Dilational Tracheostomy (PDT) is based on 5 main steps:
1. Insertion of a needle with a saline-filled syringe into the trachea and
observing for bubbles to ensure penetration into the trachea
2. Removal of the syringe and introduction of a guidewire
3. Insertion of either a series of progressively larger dilators or a conic-
shaped dilator
4. Removal of the dilator and placement of the tracheostomy tube
5. Confirmation of airway maintenance

66. PROCEDURE:
Positioning and preparing the
patient
Incision
Marking
Blunt dissection Insertion of bronchoscope and deflation
of ETT cuff until transillumination seen
Insertion of a needle to demonstrate
aspiration of air bubbles

67. Placement of a guide wire Placement of a guide catheter
Initial dilation
Sequential Dilation
(Blue Rhino kit)
Sequential Dilation
(Blue Rhino kit)
Sequential Dilation
(Blue Rhino kit)
Sequential Dilation
(Blue Rhino kit)

68. Inner cannula placed and ventilator tubing attached followed
by securing the 4 corners with sutures and attaching a velcro
trach tie.

69. Commerially available PDT kits
Blue Rhino PDT kit Griggs PDT Kit

70. COMPLICATIONS:
• False passage of the tracheostomy tube
• Pneumothorax
• Delayed bleeding
• Puncture of posterior tracheal wall
• Premature extubation during the procedure and loss of the airway.