Percutaneous Dilatational Tracheostomy

Key points

  • Percutaneous dilatational tracheostomy (PDT) is a safe procedure that can be performed at the bedside.

  • There is a learning curve associated with PDT.

  • Patient selection is important in the success of PDT.

Introduction

Tracheostomy was first described by the Greeks some 4000 years ago. Tracheostomy was subsequently documented by the Roman and Arabic literature as a method of relieving airway obstruction. This procedure is now primarily performed for those patients requiring prolonged airway assistance for its ease of managing oral secretions, elimination of dead space during mechanical ventilation, and reduction in anxiety associated with oral tracheal intubation with few complications. Open tracheostomy (OT) was the standard practice until Ciaglia and colleagues reported the first percutaneous dilatational tracheostomy (PDT) in 1985 in an effort to provide a safe, efficient, and minimally invasive way for patients in respiratory failure to obtain a secure, semipermanent airway. Since that time, both the technique and indications of PDT have undergone modifications as surgeons have gained more experience with this procedure. The average reported time to perform this procedure is approximately 15 minutes. The procedure can be safely performed at the bedside and avoids moving the patient to the operating room.

The indications for PDT ( Box 1 ) are similar to the indications for OT. These indications can be divided into the 4 broad categories:

  • 1.

    Inability to maintain or protect the airway

  • 2.

    Upper airway obstruction caused by stenosis or cancer

  • 3.

    Primary pulmonary failure requiring prolonged ventilator assistance

  • 4.

    To avoid long-term complications associated with prolonged endotracheal intubation

Box 1

  • Indications

  • Inability to maintain/protect airway

  • Upper airway obstruction/cancer (laryngectomy)

  • Prolong ventilator requirements

  • Absolute contraindications

  • Unstable cervical spine injuries

  • Coagulopathy

  • Emergency airway

  • Pediatric age (<15 years old)

  • Relative contraindications

  • Obesity

  • Short neck

  • Enlarged thyroid isthmus/goiters

  • High-riding innominate artery

  • Previous tracheostomy

  • High positive end-expiratory pressure requirement

  • High fraction of inspired oxygen (Fi o 2 ) requirement

Percutaneous tracheostomy: indications and contraindications

Tracheostomy is also performed in the setting of major maxillofacial trauma and bilateral recurrent laryngeal nerve injury.

Contraindications for PDT (see Box 1 ) are divided into absolute and relative contraindications. The absolute contraindications include unstable cervical spine injuries, coagulopathy, need for emergency airway, and age less than 15 years. Relative contraindications include the inability to palpate landmarks because of obesity and/or the presence of a short neck, enlarged thyroid isthmus/goiters, high-riding innominate artery, and previous tracheostomy.

Introduction

Tracheostomy was first described by the Greeks some 4000 years ago. Tracheostomy was subsequently documented by the Roman and Arabic literature as a method of relieving airway obstruction. This procedure is now primarily performed for those patients requiring prolonged airway assistance for its ease of managing oral secretions, elimination of dead space during mechanical ventilation, and reduction in anxiety associated with oral tracheal intubation with few complications. Open tracheostomy (OT) was the standard practice until Ciaglia and colleagues reported the first percutaneous dilatational tracheostomy (PDT) in 1985 in an effort to provide a safe, efficient, and minimally invasive way for patients in respiratory failure to obtain a secure, semipermanent airway. Since that time, both the technique and indications of PDT have undergone modifications as surgeons have gained more experience with this procedure. The average reported time to perform this procedure is approximately 15 minutes. The procedure can be safely performed at the bedside and avoids moving the patient to the operating room.

The indications for PDT ( Box 1 ) are similar to the indications for OT. These indications can be divided into the 4 broad categories:

  • 1.

    Inability to maintain or protect the airway

  • 2.

    Upper airway obstruction caused by stenosis or cancer

  • 3.

    Primary pulmonary failure requiring prolonged ventilator assistance

  • 4.

    To avoid long-term complications associated with prolonged endotracheal intubation

Box 1

  • Indications

  • Inability to maintain/protect airway

  • Upper airway obstruction/cancer (laryngectomy)

  • Prolong ventilator requirements

  • Absolute contraindications

  • Unstable cervical spine injuries

  • Coagulopathy

  • Emergency airway

  • Pediatric age (<15 years old)

  • Relative contraindications

  • Obesity

  • Short neck

  • Enlarged thyroid isthmus/goiters

  • High-riding innominate artery

  • Previous tracheostomy

  • High positive end-expiratory pressure requirement

  • High fraction of inspired oxygen (Fi o 2 ) requirement

Percutaneous tracheostomy: indications and contraindications

Tracheostomy is also performed in the setting of major maxillofacial trauma and bilateral recurrent laryngeal nerve injury.

Contraindications for PDT (see Box 1 ) are divided into absolute and relative contraindications. The absolute contraindications include unstable cervical spine injuries, coagulopathy, need for emergency airway, and age less than 15 years. Relative contraindications include the inability to palpate landmarks because of obesity and/or the presence of a short neck, enlarged thyroid isthmus/goiters, high-riding innominate artery, and previous tracheostomy.

Surgical technique

Preoperative planning

The most important aspect of preoperative planning is patient selection, which includes evaluating patients from a physiologic and anatomic standpoint. This approach cannot be overemphasized. Physiologic stability, adequate oxygenation not requiring aggressive ventilator support, and absence of coagulopathy must be ensured. The next important step is to evaluate the anatomy of the neck and palpate the landmarks of the anterior neck. The thyroid and cricoid cartilages should be palpable, along with the trachea down to the sternal notch. There should be at least 3 to 4 cm of space between the cricoid cartilage and the sternal notch ( Fig. 1 ). If these landmarks are not palpable, then PDT is contraindicated and an OT should be planned. Endotracheal intubation will already be in place for patients undergoing PDT and serves as a means to allow for oxygenation and ventilation during the procedure when sedation or general anesthetic is needed. In addition, this provides secure airway access if the PDT attempt is unsuccessful.

Fig. 1
Landmarks. 1, Thyroid cartilage; 2, cricoid cartilage; 3, first tracheal ring; 4, second tracheal ring; 5, third tracheal ring; 6, access site.
( Courtesy of Cook Medical, Inc, Bloomington, IN; with permission.)

Prep and patient position

The prep and patient positioning should be the same as in an OT. The patient should be placed on 100% fraction of inspired oxygen (Fi o 2 ) in a volume control mode of mechanical ventilation and have adequate sedation and analgesia. A shoulder roll should be placed to allow for extension of the neck. Ideally, both arms should be tucked. Betadine or chlorhexidine prep can be used from the chin to the midchest. The preparation should also include loading the tracheostomy tube onto the appropriately sized smaller, nongraduated dilator. The cuff should be checked for leaks by fully inflating it and it should then be completely collapsed.

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Jan 23, 2017 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Percutaneous Dilatational Tracheostomy
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