What is the proper procedure for performing a percutaneous tracheostomy?

Percutaneous Tracheostomy Procedure

Percutaneous dilatational tracheostomy (PDT) is a bedside technique consisting of percutaneous needle puncture of the trachea, followed by stepwise or one-time dilatation and placement of a tracheostomy tube, and should be performed with fiberoptic bronchoscopy guidance by experienced operators. 1

Pre-Procedure Requirements

Personnel and Team Composition

• Minimum of two physicians required: one operator (surgeon, intensivist, or pulmonologist) and one assistant to sedate the patient, monitor vital signs, and handle the endotracheal tube 1
• A bronchoscopist should be present for fiberoptic guidance 1
• At least one paramedic to assist with the procedure 1

Patient Preparation

• Patient must be intubated and ventilated in volume-controlled mode with FiO₂ = 1.0 (100% oxygen) 1
• General anesthesia with neuromuscular blockade is required 1
• Hyperextension of the head using a pillow under the shoulders to extend the neck 1
• Skin preparation of the surgical field with antiseptic 1
• Gastric emptying and mouth hygiene should be performed 1

Equipment Setup

• Percutaneous tracheostomy kit (single dilator technique preferred over other methods due to higher success rates) 1
• Fiberoptic bronchoscope 1
• Ultrasound (optional but recommended for identifying vascular structures and optimal puncture site) 1, 2
• Standard airway management equipment available 1
• Monitoring: SpO₂, PetCO₂, reliable IV access 1

Step-by-Step Procedure

1. Site Selection and Localization

• Identify the incision point between the 1st and 2nd tracheal rings by palpation and transillumination 1
• Ultrasound can be used to identify neck vasculature and select optimal puncture site 1, 2
• Fiberoptic bronchoscopy assists with locating the incision point through transillumination and palpation 1

2. Endotracheal Tube Positioning

• Withdraw the endotracheal tube under direct visualization and immobilize it below the glottis with the cuff inflated 1, 3
• Hyperinflate the endotracheal tube cuff before opening the trachea 3
• This step is critical to prevent accidental extubation, which is a common complication 1

3. Tracheal Access

• Perform percutaneous needle puncture of the trachea under direct bronchoscopic visualization 1
• Visualize the tracheal puncture directly through the bronchoscope 1
• Pause ventilation at key moments during tracheal entry 3
• Cover the operative site with gauze when ventilation is resumed 3

4. Dilatation and Tube Placement

• Insert guide wire through the needle under direct visualization 1
• Perform stepwise or one-time dilatation depending on the technique chosen 1
• Continue the procedure under direct bronchoscopic visualization throughout all stages (incision, guide wire placement, dilator placement, dilation) 1
• Place the tracheostomy tube under direct visualization 1

5. Post-Cannulation Verification

• Connect the tracheostomy tube to the ventilator and adjust ventilation 1
• Secure the tracheostomy tube with a device adapted to the patient's skin condition 1
• Perform endoscopic check to confirm proper tube position 1
• Verify placement with capnography and auscultation 1
• Perform bronchial hygiene therapy if necessary 1

Critical Safety Considerations

Fiberoptic Bronchoscopy Use

Fiberoptic bronchoscopy should be performed before and during percutaneous tracheotomy as it decreases early complications by 47% (95% CI 23-64%) 1. The main complications prevented include accidental extubation, perforation of the endotracheal tube cuff, and hemorrhage 1. Bronchoscopy allows direct visualization of all procedural stages and proper tube positioning 1.

Contraindications to Avoid

Absolute contraindications: skin infections and prior major neck surgery 1

Relative contraindications requiring surgical consultation: 1

• Emergency situations
• Pediatric patients
• Anatomical deformities (obesity, short neck, thyroid hypertrophy)
• Marked obesity
• Coagulopathy
• Unstable cervical spine
• Anterior cervical infection
• History of neck surgery or radiotherapy
• Difficulty identifying anatomical landmarks
• Cervical spine stiffness

Technique Selection

The single dilator technique should be preferred as it has a higher success rate compared to other percutaneous methods, though it carries a slightly higher rate of minor complications (minor bleeding and tracheal ring fractures) 1. Translaryngeal tracheotomy should be avoided due to higher failure and complication rates 1.

Training and Competency Requirements

Only airway management physicians with extensive experience in critical care medicine should perform percutaneous tracheostomy 1. The learning curve requires more than 80 consecutive procedures by the same team with the same technique 1.

Minimum Training Standards

• Trainees must perform 5-10 procedures under experienced supervision before performing independently 1
• Ten procedures per year are needed to maintain expertise 1
• Experience should be obtained through training programs or specific coursework 1

Outcomes and Complications

Expected Outcomes

Percutaneous tracheostomy has a mortality rate of 0.2% and major complication rate of 1.5% 1. It demonstrates lower early and late complication rates (including stenosis) compared to surgical tracheostomy, with better cosmetic outcomes, shorter procedure time, and greater cost-effectiveness 1.

Most Common Complications

The most frequently reported major complications are: 1

• Tracheal laceration
• False channel insertion
• Hemorrhage

Common pitfall: Failure to use bronchoscopic guidance increases risk of paratracheal puncture and posterior tracheal wall injury 2. Always maintain direct visualization throughout the procedure 1.