What are the steps involved in a tracheostomy procedure?

Tracheostomy Procedure Steps

The tracheostomy procedure follows a systematic approach with critical pre-procedural preparation, intra-procedural safety measures to minimize aerosolization, and specific technical steps that differ between open surgical and percutaneous techniques. 1, 2

Pre-Procedural Preparation

Equipment and team assembly must occur before entering the patient room to minimize contamination risk. 1

• Assemble all equipment and medications using a checklist and procedure kits prior to room entry 1
• Avoid bringing carts into the room to reduce decontamination needs 1
• Consider using a disposable bronchoscope if available 1
• Ensure minimum team of two physicians (one operator, one to manage sedation/ventilation/endotracheal tube) and at least one paramedic assistant 3
• Perform universal protocol and time-out outside the room with the procedure team 1
• Don enhanced PPE per institutional protocol before entering 1, 2

Use ultrasound pre-procedurally to assess neck anatomy, identify vascular structures, and determine the optimal point of entry. 1, 3

Patient Preparation and Positioning

Deep sedation with neuromuscular blockade is mandatory to minimize cough and agitation throughout the procedure. 1

• Intubate and ventilate in volume-controlled mode with FiO₂ = 100% 3
• Administer general anesthesia with neuromuscular blockade and monitor blockade continuously 1, 3
• Position patient with neck hyperextended using a shoulder roll 1, 3
• Prepare surgical field with antiseptic 3

Perform a pre-procedural apnea test to assess physiological stability before proceeding. 1

• Withhold ventilation (apnea) 1
• Discontinue positive end-expiratory pressure 1
• Increase FiO₂ 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 Procedure

Apnea must be maintained at specific high-risk intervals to minimize aerosol generation. 1

Key intervals requiring apnea during bronchoscopic-guided percutaneous dilational tracheostomy:

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

Percutaneous Dilational Tracheostomy (PDT) Technique

PDT should be performed with fiberoptic bronchoscopy guidance by experienced operators. 3

Step-by-Step PDT Procedure:

1. Identify the incision point between the 1st and 2nd tracheal rings using palpation and transillumination with the bronchoscope 3

2. Perform percutaneous needle puncture of the trachea under direct bronchoscopic visualization 3

3. Insert guide wire through the needle under direct visualization 3

4. Perform stepwise or one-time dilatation depending on the technique chosen (single dilator technique preferred) 3

5. Insert the tracheostomy tube over the dilator 3

6. Confirm placement bronchoscopically before connecting to the ventilator circuit 1

Place moist gauze or sponge around the guidewire during dilation and around the neck stoma to reduce aerosolization. 1

Open Surgical Tracheostomy (OST) Technique

OST involves direct surgical dissection with specific modifications to minimize aerosol generation. 2

Step-by-Step OST Procedure:

1. Identify the cricothyroid membrane as an anatomical landmark 2

2. Make an incision through the skin and platysma 2

3. Advance the endotracheal tube distal to the operative site before opening the trachea 2

4. Hyperinflate the endotracheal tube cuff 2

5. Pause ventilation at the moment of tracheal incision 2

6. Make the anterior tracheal wall incision during apnea 1, 2

7. Cover the operative site with gauze when ventilation is resumed 2

8. Insert the tracheostomy tube and secure with ties 1

Avoid or minimize the use of diathermy and suction during open tracheostomy as these carry risk of aerosolizing particles. 1

Airway Management During Procedure

Pack the oropharynx and hypopharynx to reduce aerosolization risk. 1

• Place a suction tip in the mouth to reduce aerosolization of oral secretions during endotracheal tube pullback 1
• Consider modified PDT technique with bronchoscope placed alongside the endotracheal tube while advancing the tube below the intended stomal point of entry 1

Immediate Post-Insertion Steps

Secure the tracheostomy tube immediately and confirm proper placement. 1

1. Remove the obturator immediately after tube insertion (if used) 1

2. Reposition patient to neutral position by removing the shoulder roll 1

3. Secure ties to prevent tube displacement 1

4. Inflate cuff (if present) 1

5. Lock inner cannula in place 1

Place a petrolatum gauze dressing at the fresh stoma site to prevent aerosolization or air leak until the stoma heals. 1

Choice of Technique

Both OST and PDT are acceptable techniques, with open surgical procedures preferred during high-risk situations, though percutaneous procedures are not contraindicated. 1, 2

• The choice depends on local experience and available resources 2
• Operators should only perform procedures with which they are familiar and competent 2
• PDT requires operators to have performed 5-10 procedures under supervision before independent practice 3
• Ten procedures per year are needed to maintain expertise 3

Common Pitfalls and Safety Considerations

Absolute contraindications to PDT include skin infections and prior major neck surgery. 3

Relative contraindications requiring surgical consultation include:

• Emergency situations 3
• Pediatric patients 3
• Anatomical deformities 3
• Marked obesity 3

The procedure should be performed by the smallest team with the highest level of experience to minimize exposure risk and optimize outcomes. 2