What are the steps to perform a tracheostomy?

Tracheostomy Procedure: Step-by-Step Approach

Tracheostomy should be performed using a systematic, safety-focused protocol that prioritizes pre-procedure preparation, appropriate sedation with neuromuscular blockade, and strategic apnea intervals to minimize complications and healthcare worker exposure during aerosol-generating moments. 1

Pre-Procedure Preparation

Equipment and medications must be preplanned with a checklist and procedure kits assembled before entering the room. 1

• Avoid bringing carts into the room to reduce decontamination needs 1
• Consider using a disposable bronchoscope if available 1
• Perform universal protocol and timeout outside the room with the procedure team before donning enhanced PPE per institutional protocol 1
• Use ultrasound to assess neck anatomy and identify the optimal point of entry (equipment requires standard decontamination afterward) 1

Patient Preparation and Sedation

Deep sedation and neuromuscular blockers are mandatory to minimize cough and agitation during the procedure. 1

• Before starting, perform a trial of apnea to ensure the patient can tolerate brief periods without ventilation 1
• Withhold ventilation completely during the trial 1
• Discontinue positive end-expiratory pressure (PEEP) 1
• Increase FiO2 to 100% to prevent desaturation for 30 seconds to 1 minute 1

If apnea is not tolerated, reduce ventilatory pressures and respiratory frequency to minimize aerosolization risk, or defer the procedure until ventilatory requirements improve. 1

Critical Apnea Intervals During Percutaneous Dilational Tracheostomy

Apnea must be performed at specific high-risk moments during bronchoscopic-guided percutaneous dilational tracheostomy: 1

• When adding the bronchoscope adaptor to the circuit 1
• Prior to inserting the bronchoscope into the endotracheal tube (ETT) 1
• During ETT pullback with cuff deflation 1
• During insertion of the introducer needle, angiocatheter, dilation, and tracheostomy tube insertion 1
• During bronchoscopic confirmation of placement until closed circuit connection with ventilator is established 1
• During removal of the ETT from the oropharynx 1

Airway Management During the Procedure

Pack the oropharynx and hypopharynx, and place a suction tip in the mouth to reduce aerosolization of oral secretions during ETT pullback. 1

• Place moist gauze or sponge around the guidewire during dilation and around the neck stoma as needed 1
• Ultrasound can be incorporated to avoid bronchoscopic guidance entirely 1
• A modified technique with the bronchoscope placed alongside the ETT while advancing the ETT below the intended stomal entry point may reduce aerosolization 1

Open Tracheostomy Modifications

During open tracheostomy, use apnea during ETT manipulation and prior to incising the anterior tracheal wall. 1

• Avoid or minimize diathermy and suction use as these aerosolize particles 1
• Apply the same apnea intervals as described for percutaneous technique 1

Post-Procedure Management

Place a petrolatum gauze dressing at the fresh stoma site until healing occurs to prevent aerosolization and air leak. 1

• Secure the tracheostomy tube with ties tight enough to prevent dislodgement but loose enough to allow one finger beneath the tie 2
• Maintain cuff pressure between 20-30 cmH2O to prevent tracheal injury while maintaining circuit integrity 2
• Ensure adequate humidification using heat moisture exchangers (HMEs) over large-volume humidifiers 2

Critical Safety Considerations

Healthcare workers face significant infection risk during tracheostomy, with an odds ratio of 4.2 for transmission during aerosol-generating procedures based on SARS outbreak data. 1

• Enhanced PPE (N95 mask, goggles or face shield, surgical gown, and gloves) is essential 1
• The overall complication rate for tracheostomy exceeds 50%, though serious complications are less common 3
• Life-threatening complications include decannulation, obstruction, and hemorrhage 3
• Always maintain an emergency kit at bedside containing: manual resuscitation bag, suction source, suction catheters, replacement tubes (current size and one size smaller), extra ties, shoulder roll, scissors, and emergency contact information 2