Percutaneous Tracheotomy Treatment & Management

Updated: Aug 20, 2018
  • Author: Michael Omidi, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

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.

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Preoperative Details

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). 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. 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

See the list below:

  • 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.

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Intraoperative Details

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 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 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 Percutaneous dilational tracheotomy (PDT technique). Serial dilations are performed over the guidewire.
Percutaneous dilational tracheotomy (PDT technique 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 g 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 g 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. [22] 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.

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Postoperative Details

See the list below:

  • 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.

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Follow-up

See the list below:

  • 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.

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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. Five meta-analysis studies have been published 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%). [23] 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%). [24]

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). [25] No difference was identified in overall operative complications, days intubated prior to tracheotomy, or death.

Higgins and Punthakee (2007) published a meta-analysis comparing complication rates in 15 prospective, randomized-controlled trials involving 973 patients (490 percutaneous, 483 open). [26] 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.

Halum et al collected data on complications from consecutive surgeries across 8 institutions during 2008 and 2009. The study concluded that perioperative complications are rare, but the death rate is comparatively high (22%). Obesity and use of endotracheal tubes larger than 7.5 mm in size contributed to airway stenosis. Although percutaneous tracheotomy resulted in a higher rate of posteroperative bleeding than the open method, this could be reduced by using outer flange tracheostomy tube sutures.

As PCT gains more widespread exposure, studies comparing complications of the various PCT techniques have appeared. In a 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. [27] Sheu et al reported a modification of the Ciaglia Blue Rhino (CBR) technique using a guidewire dilating forceps (GWDF) for initial dilation. [28] 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.

A study by Decker et al found that PDT can be safely performed in trauma patients, with most complications requiring no treatment. The study included 289 trauma intensive care unit patients, with complications arising in 37.4% of them, the most common being bleeding (26.3% of patients). Complications also included tracheal cartilage fracture (6% of cases), as well as guidewire dislocation, hypotension, and oxygen desaturation. [29]

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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. [30]

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. A study by Ikegami et al using a patient questionnaire and door-to-door evaluations indicated that the closed fistula in patients who had undergone PCT had a better appearance at long-term follow-up than it did in patients treated with surgical tracheotomy, including with regard to the frequency and degree of scar unevenness. [31]

A prospective study by Vargas et al of patients who underwent elective percutaneous dilatational tracheotomy (PDT) in the intensive care unit (ICU) indicated that patient age and Simplified Acute Physiology Score (SAPS) II are each independently associated with ICU mortality. Moreover, compared with neurologic disease patients 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). [32]

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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.

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