What are the steps for performing a tracheostomy?

Steps for Performing a Tracheostomy

A tracheostomy should be performed following a standardized approach with careful attention to safety measures to minimize risk of complications and ensure optimal patient outcomes. 1

Pre-Procedure Preparation

• Equipment preparation:

  • Prepare all equipment and medications with checklist prior to entering room 1
  • Avoid bringing carts into the room to reduce contamination 1
  • Consider using disposable bronchoscope if available 1
  • Ensure availability of spare tracheostomy tubes (same size and one size smaller) 1
  • Prepare suction equipment, sterile dressings, and personal protective equipment 1

• Patient preparation:

  • Perform time-out and universal protocol outside the room 1
  • Position patient with neck in slight extension using small roll under shoulders 1
  • Use ultrasound to assess anatomy and identify optimal entry point 1
  • Administer deep sedation and neuromuscular blockers to minimize cough and agitation 1

Procedure Steps

For Percutaneous Dilational Tracheostomy (PDT):

1. Perform trial of apnea to assess tolerance:

   • Withhold ventilation temporarily
   • Discontinue positive end-expiratory pressure
   • Increase FiO2 to prevent desaturation (30s-1min trial) 1

2. Prepare for key apnea intervals during:

   • Bronchoscope adaptor addition to circuit
   • Bronchoscope insertion into ETT
   • ETT pullback with cuff deflation
   • Introducer needle insertion through trachea
   • Dilation and tracheostomy tube insertion 1

3. Minimize secretion aerosolization:

   • Pack oropharynx and hypopharynx
   • Place suction in mouth during ETT pullback
   • Place moist gauze around guidewire and neck stoma 1

4. Perform tracheostomy:

   • Identify cricothyroid membrane and tracheal rings
   • Make skin incision at appropriate level (typically between 2nd-3rd tracheal rings)
   • Insert introducer needle into trachea (confirm with bronchoscopy if used)
   • Insert guidewire through needle
   • Remove needle while maintaining guidewire position
   • Dilate stoma site progressively
   • Insert appropriately sized tracheostomy tube over guidewire 1

5. Secure and confirm placement:

   • Remove obturator immediately after tube insertion
   • Confirm proper placement with capnography and/or bronchoscopy
   • Secure tracheostomy tube with ties
   • Inflate cuff if present
   • Lock inner cannula in place if applicable 1

For Open Surgical Tracheostomy:

1. Prepare as above with appropriate positioning and anesthesia

2. Perform surgical approach:

   • Make horizontal skin incision between cricoid cartilage and sternal notch
   • Dissect through subcutaneous tissue and separate strap muscles
   • Identify and divide thyroid isthmus if necessary
   • Identify tracheal rings (typically 2nd-3rd)
   • Minimize diathermy and suction to reduce aerosolization 1

3. Create tracheal opening:

   • Create window in trachea (typically removing portion of 2nd or 3rd ring)
   • Alternatively, create vertical or Bjork flap incision
   • Insert tracheostomy tube under direct visualization
   • Secure tube and confirm placement as above 1

Post-Procedure Care

1. Immediate post-procedure:

   • Apply petrolatum gauze dressing at stoma site to prevent air leak 1
   • Confirm ventilation of lungs with capnography
   • Obtain chest X-ray to confirm position and rule out complications

2. Equipment at bedside:

   • Keep spare tracheostomy tubes (same size and one size smaller)
   • Maintain suction equipment and humidification devices
   • Have scissors and emergency equipment readily available 1

Complications to Monitor

• Bleeding
• Pneumothorax
• Subcutaneous emphysema
• Tube displacement or obstruction
• Infection
• Tracheal stenosis

Special Considerations

• For COVID-19 or infectious patients, enhanced PPE and minimizing aerosol generation are critical 1
• Consider ultrasound guidance to avoid need for bronchoscopy in high-risk cases 1
• In emergency situations, be prepared to convert to surgical cricothyroidotomy if needed 1

Following these standardized steps for tracheostomy placement helps ensure patient safety and optimal outcomes while minimizing complications.