Percutaneous Tracheotomy Treatment & Management

It is worth reiterating that percutaneous tracheotomy (PCT) is ideally performed under controlled circumstances, whether in the ICU or the operating room. All necessary equipment should be present, and adequate lighting is mandatory. A team knowledgeable in the procedure should assemble and review the operative approach and plan. Backup emergency contingency plans should be reviewed in the event of a catastrophic loss of airway or other emergent or urgent complications.

Sound knowledge of the procedure and the available tools within the kit to be used is critical.

Numerous investigative reports show that all techniques for PCT (eg, guidewire dilating forceps [GWDF], Rapitrach, percutaneous dilatational 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.

With regard to the operating physician, proper training will reduce the chances of a catastrophic event that can cause harm, or even death, in an otherwise stable patient.

Patient positioning

The ideal positioning of the patient includes some neck extension, allowing the anterior structures of the neck to be placed as far forward as possible for improved palpation of relevant structures.  This can be done by placing a shoulder roll behind, in the midline, or transversely across the upper back. Obviously, in a patient with a known or suspected cervical or thoracic spinal injury, inline stabilization disallows neck extension. If the patient has undergone cervical or thoracic spine fixation, it is advisable to consult with the operating (spinal) surgeon regarding the positioning of the patient.

Equipment

See the list below:

• 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).

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• 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.

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• 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

See the list below:

• Intravenous sedation with the type and dosage of medications dictated by the clinical needs of the patient.

• Administer 100% oxygen to the patient 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 dilatational tracheotomy (PDT) technique

The neck is cleansed with an 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 or vertical skin incision is made at the level of the first and second tracheal rings. Then, blunt dissection of the midline is performed using the tips of a curved hemostat. 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. Note that the angle of entry is slightly caudad. This helps to ensure that the needle tip travels away from the endotracheal tube tip and balloon. It is ideal to have another provider performing flexible bronchoscopy so that midline needle placement can be seen. This should also help to ensure that the needle does not inadvertently enter the eyelet of the distal endotracheal tube.

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 tracheostomy tube is then introduced along the dilator and guidewire. The guidewire and dilator are removed, the cuff of the tracheostomy tube is inflated, and the breathing circuit is connected. The endotracheal tube is removed. The procedure is represented in the images below.

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

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

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

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A study by Vallejo-Díez et al indicated that in performing a PCT in patients severely infected with SARS-CoV-2 (the virus that causes coronavirus disease 2019 [COVID-19]), keeping the patient under apnea during the procedure is a safe approach that reduces the risk of virus exposure. Out of 35 PDTs performed, none of the involved healthcare providers subsequently had symptoms or a diagnosis of COVID-19. Moreover, although about one third of patients died from SARS-CoV-2–related respiratory complications, no mortality was associated with PDT. The procedure was performed under fibroscopic control via an endotracheal tube. ^[20]

Guidewire dilating forceps technique

The neck is cleansed with an 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 intravenous needle with a 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 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 endotracheal 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.

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

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Rapitrach technique

The neck is cleansed with an 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 created 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 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 tracheostomy 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 endotracheal tube is removed.

Bronchoscopic guidance of the insertion of the gauge needle and guidewire is optional but strongly recommended, especially for less-experienced operators. ^[21] 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 an 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- to 1.5-cm transverse skin incision is made at the level of the first and second tracheal rings. Then, 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 one of the three 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 are removed, the cuff of the tracheostomy tube is inflated, and the breathing circuit is connected.

The authors strongly suggest the use of fiberoptic bronchoscopy when performing PCT.  The advantages of bronchoscopic monitoring during the procedure include excellent visualization of the intratracheal area, lessening the risk of a "sidewall" injury, assessment of the trachea for undiagnosed intraluminal lesions that may impede proper placement of the tracheostomy tube, and preoperative and postoperative bronchoscopic lavage or toilet for removal of excess secretions.

The use of bronchoscopy adds to the number of personnel required. However, this is an insignificant cost, given the speed with which the procedure is normally performed and the added set of hands available in the event of a catastrophic airway loss.

A well-known—and expensive—byproduct of fiberoptic bronchoscopy–assisted PDT is the accidental puncture of the bronchoscope. This will damage fiberoptics and result in the need for expensive repairs. Shen et al reported the successful use of an adjunct to prevent this. When a rigid plastic cover with a side port, placed over a laser pointer (sheathed in a sterile glove), is used, the proper location of the needle's entry can be ensured. The side port sits at an angle to the light, while the needle is advanced. After using this novel device, Shen and colleagues reported no bronchoscope damage in 100 PDTs they performed. ^[22]

Intraoperative considerations

If electrocautery is to be used at any point in the procedure, the oxygen level must be turned down in the ventilator circuit.  It is absolutely critical for the operating surgeon and the person managing the airway to communicate with each other regarding the concomitant use of an ignition source and an oxidizer (oxygen). In such circumstances, it is wise to keep a basin of water on the field so that if a fire occurs, it can be quickly extinguished.

Postoperative considerations

Following successful PCT:

• 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

• Antiseptic wound care must be provided every day; 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

Patient care

This includes the following:

• 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 to clear secretions at least once every 8 hours

• Suction the trachea as needed

• If long-term tracheotomy is needed, arrange for continued outpatient care with a qualified therapist or other healthcare providers; ^[3]  tracheostomy tube exchange is often performed every few months

Decannulation

This process depends greatly on patient and provider variables. General considerations include the following ^[3] :

• Successful ventilator weaning can be done when promising patient characteristics (evidence of ability to protect airway) are observed
• The tube is often downsized before removal; transition to a speaking valve or fenestrated tube may assist in reestablishing phonation
• Eventually, the tube is capped for a trial period of up to a few days, making it necessary for the patient to breathe and speak through his or her natural airway; if the patient tolerates this trial well, the tracheostomy tube may be removed.

Complications of PCT mirror those of surgical tracheotomy. They can be divided into early and late complications. A simplified list is provided below. For more detailed information, please see the Complications section of Tracheostomy.

Early complications (intraoperative or postoperative)

These include the following ^{[3, 23]} :

• Bleeding (most commons)
• Intraoperative injury to nearby tissues
• Apnea/hypoxia
• Misplacement of the tube into the paratracheal space
• Inadvertent removal
• Tube occlusion
• Airway loss
• Subcutaneous emphysema
• Pneumothorax
• Infection

Late complications

These include the following ^{[3, 23]} :

• Tracheoinnominate artery fistula
• Tracheal stenosis
• Tracheoesophageal fistula
• Infection

Because 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 is related to medical problems other than PCT. Death due to PCT or related complications is relatively rare. ^[24]  A prospective study by Vargas et al of patients who underwent elective PDT in the ICU indicated that patient age and the Simplified Acute Physiology Score (SAPS) II are each independently associated with ICU mortality. ^[25] Moreover, in comparison with patients with neurologic disease who underwent PDT, those in whom the procedure was administered as a result of respiratory disease had a higher ICU mortality rate (13.6% vs 50%, respectively).​

Conditions after PCT that significantly affect patients' lives and everyday activities are few. Of all the long-term complications that require operative correction, symptomatic tracheal stenosis is the most difficult to manage, although it is relatively rare (1.9%). Hoarseness and temporary voice changes have been 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 anatomic structure injuries due to blunt tissue dissection can have favorable cosmetic results in stomal wound healing. Results of a study by Ikegami et al in which a patient questionnaire and door-to-door evaluations were used indicated that the closed fistula site in patients who had undergone PCT had a better appearance at long-term follow-up than it did in patients treated with surgical tracheotomy, even with regard to the frequency and degree of scar unevenness. ^[26]

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 be developed. 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 its drawbacks and contraindications, and the surgeon performing PCT should be aware of them when choosing his or her approach.