Percutaneous Dilatational Tracheostomy Technique

Abstract

Percutaneous dilatational tracheostomy continues to evolve as the procedure of choice for performing bedside tracheostomy tube placement in selected intensive care unit patients.1 Percutaneous tracheostomy may be performed using several different techniques; however, this “How I Do It” article pertains specifically to the percutaneous dilatational technique. The original description of the percutaneous dilatational technique was published by Ciaglia et al.2 in 1985. The procedure is based on a modified Seldinger technique using a needle/guide wire system to gain access to the airway followed by dilatation and placement of the tracheostomy tube over a guide wire/guiding catheter system. This technique is suited for physicians familiar with the modified Seldinger technique. The historical approach to securing a tracheostomy tube in a critically ill patient has been an open procedure in the operating room. Recent data suggest that bedside percutaneous dilatational tracheostomy tube placement offers many advantages compared with the open technique. Transportation of critically ill patients and use of operating room resources can be avoided. In addition, comparative studies of percutaneous versus open tracheostomy tube placement have demonstrated that the percutaneous technique yields equivalent or superior results compared with the open technique.3–8 To establish and maintain a successful percutaneous dilatational tracheostomy program requires careful planning. A dedicated percutaneous tracheostomy team, careful patient selection, attention to technical detail, and the use of a bronchoscope during the procedure has yielded the best results in our intensive care unit. The dedicated team consists of a respiratory therapist, critical care nurse, medical assistant, airway specialist with bronchoscopic skills, and the operating physician. The startup period is the most critical time when establishing this program. If possible, the operator should attend a formal training session dedicated to percutaneous dilatational tracheostomy. Ideally, the operator should perform several procedures with a physician experienced in percutaneous dilatational tracheostomy. The literature describes a learning curve for this procedure and we have found this to be true.9 The airway specialist maintains the airway and performs bronchoscopic visualization during the procedure. The intensive care unit nurse monitors vital signs and pulse oximetry, and administers necessary medications. The medical assistant aids the operating surgeon. Careful patient selection for percutaneous dilatational tracheostomy is vital to patient safety and to the success of the program. The following criteria highlight a patient population that is not ideal for percutaneous dilatational tracheostomy: anatomic neck abnormalities (scar tissue, previous tracheostomy, goiter, soft-tissue infection, hematoma, mass, previous radiation exposure, suspected or documented cervical spine injury or instability), uncontrollable coagulopathy, suspected or documented increased intracranial pressure, morbid obesity, high levels of mechanical ventilatory support, documented or suspected difficult airway, and an obstructed airway. Percutaneous dilatational tracheostomy should not be performed on pediatric patients or patients requiring an emergent airway until further data document that this procedure is safe in these populations. Bronchoscopic guidance performed during the procedure facilitates endotracheal tube repositioning, ensures that the needle, guide wire and the guiding catheter are intratracheal, and confirms airway placement of the percutaneous tracheostomy tube. The bronchoscope also facilitates airway management if the endotracheal tube is removed prematurely during the procedure. For these reasons, bronchoscopy remains an integral part of our program. In addition, the more common complications of percutaneous dilatational tracheostomy may be avoided by the use of bronchoscopy.10 TECHNIQUE OF PERCUTANEOUS DILATATIONAL TRACHEOSTOMY The following section outlines the technical aspects of the percutaneous dilatational tracheostomy procedure at our institution. Step 1 Mechanical ventilation is adjusted to provide 1.0 atm of oxygen and an adequate minute volume before the administration of a benzodiazepine, narcotic, and neuromuscular relaxing agent. If tolerated, a small towel roll is placed posterior between the scapulae to provide moderate neck extension. During the procedure the patient receives continuous pulse oximetry and frequent observation of vital signs. Intubation equipment remains at the bedside during the procedure. The percutaneous dilatational tracheostomy kit is opened and the integrity of the cuff is assessed. Step 2 The thyroid and cricoid cartilages are palpated. Subsequently, the anterior aspect of the neck is bathed with a povidone-iodine solution. Local anesthetic with epinephrine is injected into the midline dermis inferior to the cricoid cartilage. A scalpel is used to make a 1.5 to 2.0-cm incision inferior to the cricoid cartilage. Remain in the midline to avoid vascular structures. Step 3 Kelly clamps are then used to dissect bluntly the subcutaneous tissue in the sagittal plane down to the strap muscles. The first and second tracheal rings are then palpated through the incision. Blunt dissection is not absolutely necessary, however we have found the anatomy is much easier to appreciate and this process facilitates the passage of dilators (Fig. 1).FIGURE 1.: Anterior neck incision with blunt dissection in the sagittal plane using Kelly clamps.Step 4 The endotracheal tube is then repositioned by transillumination. The bronchoscopist inserts the bronchoscope into the endotracheal tube and advances it to the end of the tube. The endotracheal cuff is deflated and the bronchoscope and the endotracheal tube are withdrawn together until the operator sees the bronchoscope light through the incision. The endotracheal tube cuff is then reinflated. This typically positions the endotracheal tube in the subglottic space. Slight pressure through the incision should make an impression in the trachea that is visualized through the bronchoscope. Step 5 The first and second tracheal rings are palpated and the guide needle is inserted ideally in between these rings. As the needle enters the trachea, gas should be returned and the bronchoscopist confirms midline airway placement of the guide needle (Fig. 2). The guide wire is then passed through the guide needle, confirmed bronchoscopically. The guide needle is removed and the initial dilator is passed over the guide wire. Subsequently, the guiding catheter with the ridge distally is placed over the guide wire. The bronchoscope is then removed at this point.FIGURE 2.: Bronchoscopic view of the guide needle and guide wire in the trachea.Step 6 Over the guiding catheter and guide wire, single or multiple dilators are advanced to expand the tracheal opening.11 Appropriate lubrication should be applied to the dilators. Remember that the object is to expand the tracheal opening and not the trachea itself. During the dilations the medical assistant should stabilize the guide wire and guiding catheter so that the dilator does not advance over the guiding catheter ridge, predisposing to posterior tracheal injury or perforation. The guiding catheter and dilators are marked to help guide the appropriate depth at which these devices should be advanced (Fig. 3). Excessive force is not necessary to advance the dilators. If this is encountered, the procedure should be stopped and started over. Unfortunately, the best way to gauge the appropriate amount of force is to be guided by an operator experienced in the technique of percutaneous dilatational tracheostomy.FIGURE 3.: Single dilator inserted through the incision over the stabilized guiding catheter and guide wire. Note that the dilator is advanced to the skin-level mark.Step 7 The tracheostomy tube obturator is then lubricated and placed through the percutaneous dilatational tracheostomy tube. The obturator and the percutaneous tracheostomy tube are advanced over the stabilized guiding catheter and guide wire into the airway. The obturator, guiding catheter, and guide wire are then removed, and the bronchoscope is inserted through the tracheostomy tube to confirm airway placement. After airway confirmation, the ventilator circuit is attached to the tracheostomy tube, and the tracheostomy tube is inflated. The distance from the distal tip of the tracheostomy tube and the carina may be measured. This distance averages from 2 to 4 cm. Step 8 If desired, the bronchoscope may be reinserted through the existing endotracheal tube before removing the tube to inspect the posterior tracheal wall for injury. Step 9 The percutaneous tracheostomy tube is then secured with tracheal ties after placement of the drain sponge. The towel roll is removed and a chest radiograph is not usually necessary. DISCUSSION The practice, technology, and technique of percutaneous dilatational tracheostomy will continue to advance during the next several years. The protocol outlined earlier provides a basic template to establish a safe and successful percutaneous dilatational tracheostomy program. Emphasis on careful patient selection, establishing a multidisciplinary tracheostomy team, special attention to the procedure's technical details, and using bronchoscopy during the procedure has yielded the best results. Patient selection is self-explanatory based on the previously listed criteria. Patients with relative or absolute contraindications for percutaneous dilatational tracheostomy should be avoided, especially in newly established programs. Using a team approach to provide a service is a familiar concept in the intensive care unit environment. The growth, development, and consistency of the team approach for percutaneous dilatational tracheostomy will produce rewarding results. The literature regarding the use of bronchoscopy during percutaneous dilatational tracheostomy is conflicting; however, we strongly recommend the use of bronchoscopy during percutaneous dilatational tracheostomy for several reasons. Bronchoscopy facilitates airway management and endotracheal tube repositioning, and provides airway confirmation of the devices, avoiding paratracheal insertion—one of the more common complications of percutaneous tracheostomy. Recognizing and treating complications during and immediately after tracheostomy tube placement is imperative.12 Hemorrhage, paratracheal insertion, subcutaneous emphysema, transient hypoxia, loss of airway, failed procedure, pneumothorax, pneumomediastinum, cuff leak, posterior tracheal wall injury, and hypotension are the major concerns immediately surrounding the procedure. Fortunately major complications are uncommon with percutaneous dilatational tracheostomy. Minor hemorrhage and transient hypoxia are probably the most commonly encountered complications. Minor hemorrhage usually involves the area around the incision and can be controlled with local pressure and, if necessary, reinfiltrating the area with the local anesthetic containing epinephrine. Major incisional or tracheal bleeding should be addressed with the aid of prompt surgical consultation. Paratracheal insertion of the tracheostomy tube can be minimized with the use of bronchoscopic guidance during the procedure. Transient hypoxia will be recognized immediately with continuous pulse oximetry and is usually easy to correct. Adhering to the bronchoscopic guidelines outlined earlier will help with decreasing episodes of transient hypoxia. Persistent hypoxia should raise suspicion for other concerns including pneumothorax and correct positioning of the tracheostomy tube. Persistent hypoxia or subcutaneous emphysema should prompt the operator to obtain a chest radiograph. The complication of a failed procedure should not be viewed necessarily as a “failure.” If the operator encounters difficulties preventing successful dilatation during the procedure, rather than attempting to continue, the procedure should be aborted. This may avoid potential complications and that particular patient may be better suited for an open tracheostomy procedure. Posterior tracheal wall injury can be evaluated after tracheostomy tube placement by use of bronchoscopy. Posterior tracheal wall injuries are typically minor, such as superficial mucosal tears that heal spontaneously. However, posterior tracheal wall perforation does occur, and under certain circumstances requires surgical attention. Stabilizing the guide wire and guiding catheter during the procedure markedly decreases the rate of this complication.13 The purpose of this “How I Do It” article is to provide guidelines for the establishment and maintenance of a successful percutaneous dilatational tracheostomy program. We think that following the outlined suggestions will provide for a very successful and productive program.