Percutaneous Tracheotomy

Updated: Apr 05, 2016
  • Author: Michael Omidi, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Overview

Background

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 half century.

Since Ciaglia et al introduced the percutaneous dilatational tracheotomy (PDT), in 1985, percutaneous tracheotomy (PCT) has become increasingly popular and has gained widespread acceptance in many ICU and trauma centers as a viable alternative approach. [1] In some institutions, PCT has become the procedure of choice.

A large number of studies have been published comparing several techniques of PCT with the open surgical tracheotomy over the last 2 decades. Most studies suggest either lower complications rates with PCT or no statistical significances between the 2 methods. [2] Proponents of PCT purport smaller skin incisions, less tissue trauma, lower incidence of wound infection, and cost effectiveness. [3] Furthermore, a meta-analysis by Higgins and Punthakee demonstrated no significant difference when comparing overall complications, with a trend toward favoring percutaneous method.

Despite its substantial popularity, PCT does have limitations and risks. In Higgins and Punthakee’s meta-analysis, the percutaneous method was associated with a higher incidence of decannulation and obstruction. Furthermore, some investigators have proposed a learning curve for PCT, and increased complications result for patients who are treated by a surgeon who is inexperienced in the procedure or at an institution where the procedure is performed infrequently. [4] Therefore, early experience with PCT should be obtained under controlled settings. All surgeons using this technique should be prepared to perform immediate standard open tracheotomy to minimize the potentially lethal complications of this elective procedure.

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History of the Procedure

The percutaneous techniques developed not long after Seldinger described needle replacement over a guidewire for arterial catheterization in 1953. In 1955, Shelden et al reported the first attempt to perform PCT. [5] 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.

Subsequently, percutaneous airway access methods have improved, and various techniques and refinements have been reported.

In 1969, Toye et al reported a tracheotomy technique based on a single tapered dilator with a recessed cutting blade. [6] This dilator was advanced into the airway over a guiding catheter, and the recessed blade was designed to cut tissues under tension as the dilator was forced into the trachea.

In 1985, Ciaglia et al described the percutaneous dilational tracheotomy (PDT), a method based on needle guidewire airway access followed by serial dilations with sequentially larger dilators. [1]

Schachner et al reported the Rapitrach method in 1989. [7] This method consists of using a dilating forceps device with a beveled metal conus that is designed to advance forcibly over a wire into the airway.

In 1990, Griggs and colleagues reported the guidewire dilating forceps (GWDF) method. [8] This method is based on a forceps similar to that of the Rapitrach method, except without a cutting edge on the tip of the instrument.

1997 Fantoni translaryngeal tracheotomy using a specially designed canula to dilate the trachea in a retrograde manner. [9]

In 2000, Byhahn et al introduced the Ciaglia Blue Rhino, which is a modified version of the Ciaglia technique. [10] In this technique, dilation of the stoma is formed in a single step by means of a hydrophilically coated, curved dilator—the Blue Rhino. Therefore, the risk of posterior tracheal wall injury and intraoperative bleeding is reduced, and the adverse effect on oxygenation during repeated airway obstruction by the dilators is reduced.

In 2002, the latest variation of PCT was introduced as Frova introduced the PercuTwist technique. [11] This technique features a controlled rotating dilation using a single step dilator with a self-tapping screw. To date, little experience has been reported with this technique and thus it will not be considered in detail.

Among the various PDT techniques developed, the CBR method is currently the most commonly used PDT procedure worldwide.

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Indications

In the ICU, the most common indication for tracheotomy is a need for prolonged mechanical ventilation. This need may arise from pneumonia refractory to treatment, severe chronic obstructive pulmonary disease, acute respiratory distress syndrome, severe brain 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 percutaneous tracheotomy (PCT) are the same as those for standard open tracheotomy. Please refer to the Medscape Reference article Tracheostomy to review the main advantages of tracheotomy over prolonged translaryngeal intubation.

  • Airway obstruction due to the following:
    • Inflammatory disease
    • Congenital anomaly (eg, laryngeal hypoplasia, vascular web)
    • Foreign body that cannot be dislodged with Heimlich and basic cardiac life support (BCLS) maneuvers
    • Supraglottic or glottic pathologic condition (eg, neoplasm, bilateral vocal cord paralysis)
    • Laryngeal trauma or stenosis
    • Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the midface and mandible)
    • Edema (eg, trauma, burns, infection, anaphylaxis)
  • Need for prolonged mechanical ventilation in cases of respiratory failure
  • 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.)
  • Prophylaxis (as in preparation for extensive head and neck procedures and the convalescent period)
  • Severe sleep apnea not amendable to continuous positive airway pressure (CPAP) devices or other, less invasive surgery
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Relevant Anatomy

See Intraoperative details.

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Contraindications

What constitutes absolute and relative contraindications has become a matter of debate. Most published articles consider cervical injury, pediatric age, coagulopathy, and emergency airway necessity as absolute contraindications, whereas short, fat neck or obesity are relative contraindications. However, several reports suggesting safety and feasibility of performing PCT in patients with the previously described contraindications. [12, 13, 2, 14, 15, 16]

A retrospective study by Blankenship suggests percutaneous tracheotomy (PCT) may be performed safely in the morbidly obese patient as long as anterior neck landmarks can be palpated and in the coagulopathic patient with platelets as low as 17,000 and International Normalized Ratio. [12] Tabaee et al demonstrated the safety of percutaneous dilational tracheotomy (PDT) in patients with short neck lengths in their prospective, randomized study. [16] PCT was found to be safe and feasible even in emergency trauma cases in a case series study by Ben-Nun (2004). [2] Gravvanis et al showed in their retrospective study that PCT can be safely and more rapidly performed in burned patients with associated inhalation injury at the bedside. [14] PCT was also found to be safe and feasible in patients with cervical spine fractures in a case series by Ben-Nun et al (2006). [15]

Kornblith et al reviewed 1000 patients who underwent bedside percutaneous tracheotomy 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:

  • Patient age younger than 8 years
  • Necessity of emergency airway access because of acute airway compromise
  • Gross distortion of the neck anatomy due to the following:
    • Hematoma
    • Tumor
    • Thyromegaly (second or third degree)
    • High innominate artery
    • The relative contraindications are as follows:
  • Patient obesity with short neck that obscures neck landmarks
  • 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
  • Bleeding time longer than 10 minutes
  • Need for positive end-expiratory pressure (PEEP) of more than 20 cm of water
  • Evidence of infection in the soft tissues of the neck at the prospective surgical site
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