eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology
Percutaneous Tracheostomy: Treatment
Updated: Sep 10, 2008
Treatment
Surgical Therapy
Numerous investigative reports show that all techniques for percutaneous tracheostomy (PCT) (eg, guidewire dilating forceps [GWDF], Rapitrach, percutaneous dilational tracheostomy [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.
Preoperative Details
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 tracheostomy 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 (see Image 1), Shiley size 8 double-cannula tracheostomy tube with curved obturator, fiberoptic bronchoscope
- Rapitrach kit (Fresenius, Runcorn, Cheshire, UK): 12-gauge needle and syringe, short guidewire, scalpel, Rapitrach PCT dilator (see Image 2), standard Portex 8-mm tracheostomy tube with curved obturator, fiberoptic bronchoscope
- 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 tracheostomy 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.
Intraoperative Details
Percutaneous dilational tracheostomy 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 (see Image 3).
When air is aspirated into the syringe, the guidewire is introduced (see Image 4). After the guidewire is protected, the dilators are introduced (see Image 5). All dilators are inserted in a sequential manner from small to large diameter. The tracheostomy tube is then introduced along the dilator and guidewire (see Image 6). The guidewire and dilator are removed, the cuff of the tracheostomy tube is inflated, and the breathing circuit is connected. The ET tube is removed.
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 (see Image 1).
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 (see Image 7). To prepare the stoma of the tracheostomy, the GWDF are opened to the same diameter as the skin incision (see Image 8). A tracheostomy tube with obturator is inserted over the guidewire and advanced into the trachea. The obturator and guidewire are removed, the cuff of the tracheostomy tube is inflated, and the appropriate breathing circuit is connected. The ET tube is removed.
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 (see Image 2) 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 tracheostomy 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.17 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 tracheostomy 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 tracheostomy tube is inflated, and the breathing circuit is connected.
Postoperative Details
- 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 tracheostomy 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 tracheostomy tube cannot be immediately reinserted because the tracheostomy tract is still relatively immature.
Follow-up
- Monitor the patient to prevent dislodgment of the tracheostomy tube.
- Deliver oxygen and/or mechanical ventilation as needed to maintain the patient's oxygen saturation and maintain appropriate ventilation.
- If using a cuffed tracheostomy 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 tracheostomy (PCT) with open surgical tracheostomy, 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 tracheostomy 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%).18 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%).19
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).20 No difference was identified in overall operative complications, days intubated prior to tracheostomy, 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).21 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.22 Sheu et al reported a modification of the Ciaglia Blue Rhino (CBR) technique using a guidewire dilating forceps (GWDF) for initial dilation.23 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.
Summary of comparative studies results
Open table in new window
Table
| 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 |
| 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.
More on Percutaneous Tracheostomy |
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| Workup: Percutaneous Tracheostomy |
 Treatment: Percutaneous Tracheostomy |
| Follow-up: Percutaneous Tracheostomy |
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Further Reading
Keywords
percutaneous tracheostomy, tracheostomy, PCT, percutaneous dilational tracheostomy, PDT, guidewire dilating forceps, GWDF, Rapitrach method, mechanical ventilation, airway obstruction, inflammatory disease, benign laryngeal pathology, webs, cysts, papilloma, malignant laryngeal tumors, laryngeal trauma, laryngeal stenosis, tracheal stenosis, pulmonary toilet, obstructive sleep apnea
