Percutaneous Tracheotomy Treatment & Management

Author: Scott E Brietzke, MD, MPH; Chief Editor: Arlen D Meyers, MD, MBA more...

Updated: Mar 16, 2011

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Surgical Therapy
Preoperative Details
Intraoperative Details
Postoperative Details
Follow-up
Complications
Outcome and Prognosis
Future and Controversies
Show All

Surgical Therapy

Numerous investigative reports show that all techniques for percutaneous tracheotomy (PCT) (eg, guidewire dilating forceps [GWDF], Rapitrach, percutaneous dilational tracheotomy [PDT]) have similar success rates. All techniques are based on the use of a needle guidewire to gain airway access. However, each method requires unique equipment and follows a different intraoperative procedural sequence. For example, all techniques that are conducted by serial dilatations of the stoma with commercial dilatators could be classified under PDT.

Equipment

PDT kit (Cook Critical Care Inc, Bloomington, IN): 22-gauge needle and syringe; 11-F short punch dilator; 1.32-mm guidewire; 8-F guiding catheter; 18-F, 21-F, 24-F, 28-F, 32-F, 36-F, and 38-F dilators; Shiley size 8 double-cannula tracheotomy tube; fiberoptic bronchoscope
GWDF kit (Sims Portex): 14-gauge needle and syringe, guidewire (J-tipped Seldinger wire type), scalpel, Howard-Kelly forceps modified to produce a pair of GWDF (seen in the image below), Shiley size 8 double-cannula tracheotomy tube with curved obturator, fiberoptic bronchoscope Guidewire dilator forceps (GWDF).
Rapitrach kit (Fresenius, Runcorn, Cheshire, UK): 12-gauge needle and syringe, short guidewire, scalpel, Rapitrach PCT dilator (seen in the image below), standard Portex 8-mm tracheotomy tube with curved obturator, fiberoptic bronchoscope Rapitrach dilating forceps.
Ciaglia Blue Rhino kit (Cook Critical Care Inc, Bloomington, IN): 14-gauge catheter introducer needle and syringe, guidewire (J-tipped Seldinger wire type), guiding catheter, introducer dilator, loading dilators, single tapering Blue Rhino dilator, Shiley size 8 double-cannula tracheotomy tube with curved obturator; fiberoptic bronchoscope

Anesthesia

Intravenous sedation with the type and dosage of medications dictated by the clinical needs of the patient
Place the patient on 100% oxygen throughout the procedure.
Hyperextend the patient's neck if no contraindications exist. Before preparation of the surgical area begins, withdrawal of the endotracheal tube under direct vision of bronchoscope is recommended to place the balloon just under the vocal cords. The respiratory therapist then protects the tube against any further movement during the procedure.
Infiltrate the incision site with a solution of 1-2 2% lidocaine with 1:100,000 epinephrine.

Percutaneous dilational tracheotomy technique

The neck is cleansed with antiseptic solution and properly draped. The cricoid cartilage is identified, and the skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1.5- to 2-cm transverse skin incision is made on the level of the first and second tracheal rings. Then, the blunt dissection of the midline is performed. A 22-gauge needle is inserted between the first and second or the second and third tracheal rings. This is represented in the image below.

Percutaneous dilational tracheotomy (PDT technique). Needle access of airway after blunt dissection of pretracheal tissues.

When air is aspirated into the syringe, the guidewire is introduced. After the guidewire is protected, the dilators are introduced. All dilators are inserted in a sequential manner from small to large diameter. The tracheotomy tube is then introduced along the dilator and guidewire. The guidewire and dilator are removed, the cuff of the tracheotomy tube is inflated, and the breathing circuit is connected. The ET tube is removed. The procedure is represented in the images below.

Percutaneous dilational tracheotomy (PDT technique). After removing the needle and reaspirating to confirm catheter location in the airway, the guidewire is placed.

Percutaneous dilational tracheotomy (PDT technique). Serial dilations are performed over the guidewire.

Percutaneous dilational tracheotomy (PDT technique). A tracheotomy tube is inserted in the dilated passageway using a dilator as obturator over the guidewire.

Guidewire dilating forceps technique

The neck is cleansed with antiseptic solution and properly draped. The neck is palpated, and the cricoid cartilage is identified. The skin below this level is anesthetized with 1% lidocaine with 1:100,000 epinephrine solution. A 1.5- to 2-cm midline transverse cutaneous incision is made at this level. A 14-gauge IV needle with syringe is inserted in the midline of the incision. The needle is directed to pass between the first and second or the second and third tracheal rings. As soon as air begins to bubble into the syringe, the outer plastic cannula is advanced into the lumen of the trachea and the inner needle is removed. A J-tipped Seldinger wire is introduced into the trachea, and the plastic cannula is removed. The tip of the Seldinger wire is passed through the closed GWDF.

The forceps are advanced through the soft tissues of the neck until resistance is felt. The GWDF are opened to dilate the soft tissues anterior to the trachea. The forceps are then closed and reinserted over the wire into the trachea. A slight loss of resistance occurs as the tracheal membrane is pierced. To prepare the stoma of the tracheotomy, the GWDF are opened to the same diameter as the skin incision. A tracheotomy tube with obturator is inserted over the guidewire and advanced into the trachea. The obturator and guidewire are removed, the cuff of the tracheotomy tube is inflated, and the appropriate breathing circuit is connected. The ET tube is removed. The procedure is represented in the images below.

Guidewire dilating forceps (GWDF) technique. The guidewire dilator forceps are advanced along the Seldinger wire into the long axis of the trachea.

Guidewire dilating forceps (GWDF) technique. The guidewire dilator forceps enlarge the hole between tracheal rings.

Rapitrach technique

The neck is cleansed with antiseptic solution and properly draped. The skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1.5- to 2-cm skin incision is performed at the level of the first and second tracheal rings. Subcutaneous layers are then bluntly dissected with a pair of forceps. Blunt dissection is continued until the tracheal rings can be palpated with a finger. A 12-gauge needle is inserted into the trachea between the first and second or the second and third rings. A short, flexible guidewire is inserted into the trachea, and the needle is removed.

The Rapitrach dilator is introduced into the trachea over the guidewire. The dilator is opened when its tip lies in the trachea. A tracheotomy tube with obturator is inserted through the dilator jaws to the trachea. The dilator and guidewire are removed, the cuff of the tracheotomy tube is inflated, and the breathing circuit is connected. The ET tube is removed.

Bronchoscopic guidance of the gauge needle and the guidewire insertion is optional but strongly recommended, especially for less-experienced operators.^[18]A large number of paratracheal cannula insertions and pneumothoraces can be avoided if endoscopic monitoring is employed. Bronchoscopic monitoring also allows patients with short, fat necks to undergo PCT. However, bronchoscopic guidance during PCT appears to be the most important factor responsible for the hypercarbia that develops during the procedure. Therefore, bronchoscopic guidance should be limited to initial dilatation steps only.

Ciaglia blue rhino technique

The neck is cleansed with antiseptic solution and properly draped. The cricoid cartilage is identified, and the skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1-1.5 cm transverse skin incision is made on the level of the first and second tracheal rings. Then, the blunt dissection of the midline is performed. A 14-gauge angiocatheter is inserted between the first and second or the second and third tracheal rings.

When air is aspirated into the syringe, the guidewire is introduced. After the guidewire is protected, the Blue Rhino single tapering dilator is introduced over the guidewire until the stoma is dilated to an adequate diameter (36-F to 38-F). Once dilation is achieved, the tracheotomy cannula is assembled with 1 of the 3 intermediate dilators. Once assembled, it is advanced over the guidewire until the cannula is in place within the tracheal lumen. The intermediate dilator and guidewire is removed, the cuff of the tracheotomy tube is inflated, and the breathing circuit is connected.

Air entry into the lungs is checked by chest auscultation and respiratory plethysmography.
Excess secretions or blood should be suctioned to prevent a drop in oxygen saturation and to provide good bronchopulmonary hygiene.
Everyday antiseptic wound care must be provided. A tracheotomy tube with an inner cannula facilitates care and hygiene and ensures added safety (due to easy removal) if obstruction from secretions occurs.
In the event of accidental decannulation within 5-7 days of the procedure, the patient may need to be reintubated orally if the tracheotomy tube cannot be immediately reinserted because the tracheotomy tract is still relatively immature.

Monitor the patient to prevent dislodgment of the tracheotomy tube.
Deliver oxygen and/or mechanical ventilation as needed to maintain the patient's oxygen saturation and maintain appropriate ventilation.
If using a cuffed tracheotomy tube, monitor cuff pressure carefully because prolonged inflation and/or overinflation can lead to tracheal mucosal injury.
Clean the inner cannula as much as needed to clear secretions at least once every 8 hours.
Suction the trachea as needed.

Complications

Numerous articles have been published comparing several techniques of percutaneous tracheotomy (PCT) with open surgical tracheotomy, as well as with one another. In general, most have shown similar complication rates. Four meta-analysis studies have been published in the last decade comparing percutaneous and open tracheotomy methods.

In a meta-analysis of studies (1985-1996), Dulguerov et al found more frequent perioperative complications in the percutaneous cohort (10% vs 3%) but more postoperative complications with the surgical approach (10% vs 7%).^[19]Also noted was a higher incidence of perioperative death (0.44 vs 0.03%) and serious cardiorespiratory events (0.33% vs 0.06%) in the percutaneous group.

Cheng and Fee (2000) analyzed 4 studies showing PCT required shorter operative times (8 minutes vs 20.9 minutes for the ST group), produced less intraoperative minor bleeding (9% vs 25%), and postoperative bleeding (7% vs 18%), and resulted in fewer overall postoperative complications (14% vs 60%), which included stomal infection (4% vs 29%), pneumothorax (1% vs 4%), and death (0% vs 3%).^[20]

Freeman et al (2000) analyzed 5 studies (n=236 patients) and found that percutaneous method was associated with shorter operative time (absolute difference 9.84 minutes), less perioperative bleeding (OR with 95% CI, 0.14), lower overall postoperative complication rate (OR 0.14), and lower postoperative incidence of bleeding (OR 0.39) and stomal infection (OR 0.02).^[21]No difference was identified in overall operative complications, days intubated prior to tracheotomy, or death.

Higgins and Punthakee (2007) recently published a meta-analysis comparing complication rates in 15 prospective, randomized-controlled trials involving 973 patients (490 percutaneous, 483 open).^[22]See the table below for a summary of the results. This meta-analysis showed no significant difference when comparing overall complications, with a trend toward favoring percutaneous method. However, the more serious and life-threatening complication of decannulation/obstruction was more likely to occur with the percutaneous technique and false passage trended toward favoring the open procedure. Nevertheless, no significant difference was shown between the 2 methods in regards to death.

As PCT gains more widespread exposure, studies comparing complications of the various PCT techniques have appeared. In a recent study comparing PercuTwist to PDT and guidewire dilating forceps (GWDF) techniques, the PercuTwist was found to require shorter procedure times (5.4 minutes +/- 1.2 minutes vs 9.9+/-1.1 and 6.2+/-1.4, respectively) and similarly acceptable complication rates.^[23]Sheu et al reported a modification of the Ciaglia Blue Rhino (CBR) technique using a guidewire dilating forceps (GWDF) for initial dilation.^[24]In their case series comparing GWDF-CBR (n=114) with standard CBR (n=120), they found shorter procedure times (4.5 +/- 1.6 minutes vs 5.7 +/- 3.0 minutes, P< 0.001), as well as fewer overall procedure-related complications (13.1% vs 27.5%, P=0.006). As time goes on, similar comparative studies will be performed, perhaps better elucidating optimal methods of PCT.

Table. Summary of comparative studies results (Open Table in a new window)

Complication	Pooled OR	95% CI	P value
Decannulation/obstruction	2.79	1.29-6.03	0.009
False passage	2.70	0.89-8.22	0.08
Minor hemorrhage	1.09	0.61-1.97	0.77
Major hemorrhage	0.60	0.28-1.26	0.17
Wound infection	0.37	0.22-0.62	0.0002
Unfavorable scarring	0.44	0.23-0.83	0.01
Subglottic stenosis	0.59	0.27-1.29	0.19
Death	0.70	0.24-2.01	0.50
Overall complications	0.75	0.56-1.00	0.05

When comparing costs, procedure time, and personnel involved, the percutaneous method appears to have the advantage ($461 USD less, 4.59 minutes less, 1 individual less). The decreased amount of time and personnel required for the percutaneous method is possibly because it is more likely to be performed by more experienced personnel, while trainees were more likely to perform the open technique.

Outcome and Prognosis

Because percutaneous tracheotomy (PCT) is performed in critically ill patients, late outcome of the procedure is difficult to describe. The mortality rate is high, but this high rate related to medical problems other than PCT. Mortality because of PCT or related complications is relatively rare.

Conditions after PCT that significantly affect patients' lives and everyday activities are few. Symptomatic tracheal stenosis, the most difficult long-term complication to manage that requires operative correction, is relatively rare (1.9%). Hoarseness and temporary voice changes were reported by a significant number of patients (with a prevalence of up to 50%). In most cases, however, these changes are related to previous translaryngeal intubation. Direct injuries to the vocal cords or recurrent laryngeal nerve are extremely rare. Small skin incisions and few adjacent anatomical structure injuries due to blunt tissue dissection lead to favorable cosmetic results in stomal wound healing.

Future and Controversies

Percutaneous tracheotomy (PCT) has undergone and continues to undergo rigorous evaluation regarding its safety and the simplicity of its techniques. New percutaneous methods as well as modifications of the currently popular techniques have continued to develop. As new methods are introduced, future prospective randomized clinical studies would be helpful. PCT has been shown to be a safe and viable alternative to the standard open tracheotomy technique. However, this method has drawbacks and contraindications, and the surgeon performing PCT should be aware of them when making the decision as to which approach to use.

Contributor Information and Disclosures

Author

Scott E Brietzke, MD, MPH Assistant Professor of Surgery, Uniformed Services University of the Health Sciences; Director, Pediatric Otolaryngology, Department of Surgery, Otolaryngology Service, Walter Reed Army Medical Center; Associate Program Director, National Capital Consortium Residency in Otolaryngology

Scott E Brietzke, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, and American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Michael S Kong, MD Resident Physician, Department of Otolaryngology, National Capital Consortium

Michael S Kong, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Medical Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Joshua S Schindler, MD Assistant Professor, Department of Otolaryngology, Oregon Health and Science University

Joshua S Schindler, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Darius Bliznikas, MD Staff Physician, Department of Otolaryngology, Wayne State University School of Medicine

Darius Bliznikas, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.

Soly Baredes, MD Associate Professor of Clinical Surgery, Chief, Section of Otolaryngology-Head and Neck Surgery, Director, Division of Head and Neck Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Soly Baredes, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, American Society for Head and Neck Surgery, New York Academy of Medicine, New York Academy of Sciences, New York Head and Neck Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons

Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gregory C Allen, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society

Disclosure: Nothing to disclose.

Christopher L Slack, MD Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

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Guidewire dilator forceps (GWDF).

Rapitrach dilating forceps.