Percutaneous Tracheotomy

Updated: Nov 03, 2020
  • Author: Roy R Danks, DO, FACOS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Overview

Practice Essentials

Percutaneous tracheotomy (PCT) should generally be considered an elective procedure. Although emergent application of PCT has been reported in the literature, one might be better off considering a cricothyroidotomy, given its relative ease of performance and limited need for specialized equipment to complete the task. The overall goal in such patient care, regardless of how it is achieved, is to provide a long-term, secure airway and to take into account airway protection, maintenance, and pulmonary toilet.

Providers wishing to perform PCT must have proper training in the procedure before attempting the operation. Improper or inadequate performance may result in loss of airway and death. Further, the provider must be trained in and comfortable with:  control of unexpected bleeding, alternatives to the planned procedure (should complications arise), relevant anatomy, and follow-up care of the tracheotomy. The provider must know when to downsize and decannulate and how to diagnose and manage complications such as tracheal stenosis, innominate artery stenosis, or tracheoinnominate fistula formation.

Most PCTs are performed rather quickly and with few immediate complications. However, this is a surgical procedure during which dire consequences can arise. Failure to plan for these consequences may result in catastrophic outcomes.  Proper training and planning, as well as having backup options and plans, are paramount.

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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, PCT has become increasingly popular and has gained widespread acceptance in many intensive care units (ICUs) as a viable alternative approach. [1, 2] In some institutions, PCT has become the procedure of choice.

As with any invasive procedure, substantial risks are involved; these include bleeding, infection, injury to nearby aerodigestive structures, and catastrophic airway loss leading to hypoxia, anoxia, or even death. However, in well-trained hands, the procedure can be safely carried out at the bedside in the intensive care setting or in the operating room. Variations in technique stem from surgeon preference regarding the available pre-packaged supplies, as well as individual experience.

Multiple studies that provide clear support for the less invasive percutaneous methods have been published. The most consistently reported benefits include decreased rate of surgical site infection, reduced operative time, and lower procedure cost. [3]  Although it is beyond the scope of this article, the actual timing of the procedure depends on numerous factors. Ultimately, the physician providing the long-term ventilator care will determine the proper time to undertake this advanced airway procedure.  

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History of the Procedure

The percutaneous airway techniques that were developed not long after Seldinger described needle replacement over a guidewire for arterial catheterization (1953) have evolved to the present-day versions. In 1955, Shelden et al reported the first attempt to perform PCT. [4] 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.

Percutaneous airway access methods have subsequently improved, and various techniques and refinements have been reported.

Although a tracheotomy technique based on a single tapered dilator with a recessed cutting blade was reported as early as 1969, [1]  several variations of PCT appeared in the years that followed. [5, 6, 7]

Then, in 2000, Byhahn et al introduced the Ciaglia Blue Rhino technique, which is a modified version of the Ciaglia technique. [8]  When this procedure is used, dilation of the stoma is formed in a single step, utilizing a curved, tapered dilator coated with hydrophilic material—the Blue Rhino. This method reduces the risks of posterior tracheal wall injury and intraoperative bleeding, as well as the adverse effects on oxygenation caused by repeated airway obstruction during serial dilation. 

Some of the most recent techniques were developed in the mid-2000s and include the PercuTwist technique [9] and a balloon dilation technique. [3]  Among the various PDT techniques developed, the Ciaglia Blue Rhino method is probably the most commonly used worldwide.

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Indications

In the ICU, the most common indication for tracheotomy is the need for prolonged mechanical ventilation, occurring in 5-10% of the ICU population. [3] This need may arise from pneumonia refractory to treatment, severe chronic obstructive pulmonary disease, acute respiratory distress syndrome, severe brain injury, smoke inhalation 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 PCT are the same as those for standard open tracheotomy. Please refer to the Medscape Drugs & Diseases article Tracheostomy to review the main advantages of tracheotomy over prolonged translaryngeal intubation.

Airway obstruction may be 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)

Indications for PCT also include the following:

  • Need for prolonged mechanical ventilation in patients experiencing 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 amenable to continuous positive airway pressure (CPAP) devices or other, less invasive surgery

Special consideration is required for creation of a tracheotomy in patients with burn injuries. Such individuals may require surgical control of the airway immediately after injury and on a long-term basis as the injuries heal. In the acute setting, neck burns often accompany facial burns, and both facial and neck burns are commonly associated with inhalation injury. In patients with burns who arrive intubated, but with risk of loss of airway due to ensuing facial edema, tracheotomy may be indicated.

Although there is no strict contraindication for percutaneous (dilatational) tracheotomy in patients with burn injuries, the physician is cautioned about performing it in these individuals. The edema accompanying deep burns of the anterior neck can result in loss of tissue planes and increase the difficulty of the operation. Added to this is the risk of loss of an orotracheal or nasotracheal tube already in place. Because the risk of airway loss is significant, extreme caution is advised. As with other patients with complicated injuries and those at high risk for poor outcomes, a formal tracheotomy performed in the operating room may be a better option.

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Contraindications

 

Determination of absolute and relative contraindications remains a matter of debate. In most published articles, cervical injury, pediatric age, coagulopathy, and a need for an emergency airway are considered absolute contraindications, whereas a short, fat neck and obesity are relative contraindications. However, there have been several reports suggesting that performance of PCT in patients with the previously described contraindications can be safe and feasible. [10, 11, 12, 13, 14, 15, 16]

In a retrospective study, Blankenship et al suggested that PCT may be performed safely in a patient with morbid obesity as long as anterior neck landmarks can be palpated and in a patient with coagulopathy who has a platelet count as low as 17,000 and an international normalized ratio of 1.7. [10] Tabaee et al demonstrated the safety of PDT in patients with short neck lengths in their prospective, randomized study. [15] PCT was found to be safe and feasible even in emergency trauma cases in a case series study by Ben-Nun et al, [12] while Gravvanis et al [13] showed, in their retrospective study, that PCT can be safely and more rapidly performed in patients with burns and associated inhalation injury at the bedside. PCT was also found to be safe and feasible in patients with cervical spine fractures in a case series by Ben-Nun and colleagues. [14]

Kornblith et al reviewed data for 1000 patients who underwent bedside PCT 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

  • The 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

Relative contraindications are as follows:

  • Patient obesity with a 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

PCT is no longer considered absolutely contraindicated in patients with necks that are difficult to extend (eg, due to trauma or previous cervical fixation) or previous PCT. In fact, the previous site of PCT provides a reliable access site, and wound healing in the scar has not proven to be an issue. [3]  Clinical judgment is used on a case-by-case basis to determine safety and feasibility.

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Relevant Anatomy

A plexus of veins is found in the neck, including veins that drain the thyroid, the inferior laryngeal vein, and the anterior jugular vein. Although these veins are not visualized during PDT, it is necessary to know their approximate location and the inherent risk of bleeding should one of these vessels be injured. Given that the incision for PDT is small, there will be limitations to accessing the cut ends of bleeding vessels. Absorbable suture material should be available for vessel ligation.

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Preoperative Workup

Laboratory Studies

These include the following:

  • 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: Check 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

Imaging

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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