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Percutaneous Tracheotomy Workup

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

Laboratory Studies

See the list below:

  • Complete blood count: Platelet count must be more than 50,000/µL.
  • Coagulation profile: Prothrombin time or activated partial thromboplastin time must be less than 1.5 times the reference range.[18, 19]
  • Bleeding time: Bleeding time should be checked if blood urea nitrogen is more than 40 mg/dL or if the creatinine level is above 4 mg/dL. Bleeding time must be less than 10 minutes.
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Imaging Studies

A standard chest radiograph can provide information regarding the tracheal air column. Anteroposterior filtered tracheal views and lateral soft tissue views of the neck provide information regarding the glottic and subglottic air columns.

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Contributor Information and Disclosures
Author

Michael Omidi, MD, FACS 

Michael Omidi, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Soly Baredes, MD Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Director of Otolaryngology-Head and Neck Surgery, University Hospital

Soly Baredes, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Laryngological Association, The Triological Society, American Medical Association, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, Triological Society, New York Head and Neck Society, New York Laryngological Society, New Jersey Academy of Otolaryngology-Head and Neck Surgery, The New Jersey Academy of Facial Plastic Surgery, International Skull Base Society

Disclosure: Nothing to disclose.

Mark S Granick, MD, FACS Professor of Surgery, Chief, Division of Plastic Surgery, Rutgers New Jersey Medical School

Mark S Granick, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons, Phi Beta Kappa, Northeastern Society of Plastic Surgeons, New Jersey Society of Plastic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Waterjel, Inc.; Reconstat, LLC; DSM<br/>Serve(d) as a speaker or a member of a speakers bureau for: Novadaq<br/>Received none from Waterjel Inc. for board membership; Received none from Reconstat LLC for board membership; Received none from Open Science Co., LLC for board membership.

Sammy D D Eghbalieh, MD Fellow in Vascular Surgery, Division of Vascular Surgery, Albany Medical College

Sammy D D Eghbalieh, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Medical Association, California Medical Association, Physicians for Social Responsibility, Society for Vascular Surgery, Vascular and Endovascular Surgery Society

Disclosure: Nothing to disclose.

Ronnie A Pezeshk, MD Clinical Research Fellow in Plastic and Reconstructive Surgery, University of Texas Southwestern Medical Center

Disclosure: Nothing to disclose.

Evelyne Kalyoussef, MD, FACS Assistant Professor, Otolaryngology Residency Program Director, Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Attending Physician, Department of Otolaryngology-Head and Neck Surgery, University Hospital and Hackensack University Mountainside Hospital

Evelyne Kalyoussef, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, Association of Women Surgeons, European Rhinologic Society, North American Skull Base Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

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 Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, New York Academy of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Soly Baredes, MD Professor of Otolaryngology-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: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Society for Head and Neck Surgery, New York Head and Neck Society, North American Skull Base Society, Society of UniversityOtolaryngologists-Head and Neck Surgeons, and Triological Society

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.

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.

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.

References
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Guidewire dilator forceps (GWDF).
Rapitrach dilating forceps.
Percutaneous dilational tracheotomy (PDT technique). Needle access of airway after blunt dissection of pretracheal tissues.
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 (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.
Thin lines from top to bottom indicate thyroid cartilage, cricoid cartilage, first tracheal cartilage, second tracheal cartilage, and third tracheal cartilage. Arrows indicate access sites, optimally between the first and second tracheal rings or second and third tracheal rings. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Ciaglia Blue Rhino® kit; from left to right: FEP catheter introducer needle, J-tip guidewire (TFE-coated stainless steel) with safety ridge and guiding catheter, Ciaglia Blue Rhino® G2 advanced dilator (radio-opaque), and dilator assembly. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Ciaglia Blue Rhino® kit with multidilator kit. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Tracheostomy tube with loading dilator, deflated balloon. The tracheostomy tube should fit snugly on the dilator. Ensure that the balloon is completely deflated. Thoroughly lubricate the tracheostomy tube assembly. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Verify entrance into the tracheal lumen via aspiration on the syringe resulting in air bubble return. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Remove the FEP sheath or introducer needle while maintaining the position within the tracheal lumen. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Percutaneous dilational tracheotomy (PDT) technique. Serial dilations are performed over the guidewire. To properly align the dilator on the guidewire/guiding catheter assembly, take care not to advance the Ciaglia Blue Rhino® G2 advanced dilator beyond the black, skin-level mark. This will prevent injury to the posterior tracheal wall. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Percutaneous dilational tracheotomy (PDT) technique. A tracheotomy tube is inserted into the dilated passageway using a dilator as obturator over the guidewire. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Ideally, tube placement is made at the level between the first and second tracheal cartilages or between the second and third tracheal cartilages. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Puncture in the trachea is performed by directing the needle, in the midline, posterior and caudal. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Remove the FEP sheath or introducer needle while maintaining the wire guide position within the tracheal lumen. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
With the balloon fully deflated, advance the balloon catheter and tracheostomy tube assembly as a unit over the guidewire while maintaining the position of the distal wire guide marking at the skin level. Align the proximal end of the balloon catheter at the mark on the proximal portion of the wire guide. This will ensure the distal end of the balloon catheter is correctly aligned on the guidewire, preventing possible trauma to the posterior tracheal wall during subsequent manipulations. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
While maintaining the visual reference points and positioning relationships of the wire guide and balloon catheter assembly, inflate the balloon. To avoid balloon rupture, do not exceed 11 atm. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Advance the deflated balloon catheter/loading dilator/tracheostomy tube/wire guide assembly as a unit into the trachea. Permission for use granted by Cook Medical, Inc., Bloomington, Indiana.
Table. Summary of comparative studies results
Complication Pooled OR 95% CI P value
Decannulation/obstruction2.791.29-6.030.009
False passage2.700.89-8.220.08
Minor hemorrhage1.090.61-1.970.77
Major hemorrhage0.600.28-1.260.17
Wound infection0.370.22-0.620.0002
Unfavorable scarring0.440.23-0.830.01
Subglottic stenosis0.590.27-1.290.19
Death0.700.24-2.010.50
Overall complications0.750.56-1.000.05
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