How can I explain the procedure, indications, and steps for a percutaneous tracheostomy and its possible conversion to an open tracheostomy in an intubated adult requiring long‑term airway support?

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Last updated: August 13, 2026 • View editorial policy

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How to Explain Percutaneous (Possibly Open) Tracheostomy

Percutaneous tracheostomy is the standard method for creating a surgical airway in intubated ICU patients requiring long-term mechanical ventilation, with surgical tracheostomy reserved for specific anatomical or clinical contraindications. 1

Indications for Tracheostomy

The primary indication is anticipated need for mechanical ventilation beyond 7-10 days 2. Additional indications include:

  • Facilitating weaning from mechanical ventilation
  • Improving airway access for secretion management
  • Reducing sedation requirements
  • Enhancing patient comfort and communication 3
  • Preventing laryngeal injury from prolonged translaryngeal intubation 4

Why Percutaneous is Preferred

The percutaneous technique should be the default approach whenever feasible 1. Compared to surgical tracheostomy, percutaneous dilatational tracheostomy offers:

  • Shorter operative time
  • Lower incidence of stoma infection and inflammation 1
  • Bedside performance without operating room scheduling
  • Reduced cost (approximately $1,750 savings per procedure) 5
  • Equivalent safety profile regarding mortality and major complications 1

The single dilator percutaneous dilatational technique is recommended as the standard method, as translaryngeal approaches show higher failure and complication rates 1.

When Conversion to Open Surgical Tracheostomy is Necessary

Certain anatomical and clinical situations make percutaneous tracheostomy difficult or impossible, requiring surgical approach 1:

Relative Contraindications to Percutaneous Approach:

  • Anatomical difficulties: Obesity, short neck, thyroid hypertrophy, inability to identify landmarks
  • Cervical spine instability or stiffness
  • Anterior cervical infection
  • Previous neck surgery or radiotherapy
  • Severe coagulopathy (though this requires individualized assessment)
  • Severe hypoxia requiring maximal oxygen support 2

These situations should prompt discussion between medical and surgical teams to determine the optimal approach 1. An experienced team with ultrasound guidance, bronchoscopy, and specialized equipment may still attempt percutaneous tracheostomy in some at-risk situations 1.

Procedural Steps for Percutaneous Tracheostomy

Pre-Procedural Preparation:

  • Position patient supine with neck extension (shoulder roll)
  • Withdraw endotracheal tube to just below vocal cords under direct visualization
  • Use ultrasound pre-procedurally to identify vascular structures and select optimal puncture site 3
  • Prepare for bronchoscopic guidance throughout procedure 3

Technique:

  1. Make small horizontal skin incision between 1st and 2nd or 2nd and 3rd tracheal rings
  2. Insert introducer needle into tracheal lumen under bronchoscopic visualization
  3. Ultrasound can guide accurate needle placement intra-procedurally 3
  4. Pass guidewire through needle
  5. Perform serial dilation over guidewire (single dilator technique preferred) 1
  6. Insert appropriately sized tracheostomy tube
  7. Confirm placement bronchoscopically
  8. Post-procedural ultrasound to evaluate for pneumothorax 3

Critical Safety Points:

  • Bronchoscopy provides real-time visual guidance and reduces complications including paratracheal puncture and posterior tracheal wall injury 3
  • The procedure should only be performed by physicians experienced in airway management with immediate capability to perform surgical tracheostomy if complications arise 6
  • Conversion rate to surgical tracheostomy is approximately 6% (2 of 33 in one series) 5

Team-Based Approach

The procedure can be performed by otolaryngologists, general surgeons, interventional pulmonologists, thoracic surgeons, or intensivists 2. The key requirement is experience with the technique and immediate surgical backup availability 6.

Common Pitfalls to Avoid

  • Attempting percutaneous approach in patients with difficult anatomy without appropriate adjuncts (ultrasound, bronchoscopy, specialized equipment)
  • Proceeding without surgical backup immediately available
  • Inadequate pre-procedural ultrasound assessment of vascular structures
  • Performing procedure without bronchoscopic guidance, which significantly reduces complications 3

References

5
Research

Percutaneous dilational tracheostomy for airway control.

American journal of surgery, 1997

6
Research

[Tracheostomy in intensive care].

Der Anaesthesist, 1999

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