What is the recommended technique for performing a tracheostomy?

Tracheostomy Technique

Percutaneous dilatational tracheostomy (PDT) is the standard technique for tracheostomy in intensive care patients, performed at the bedside with fiberoptic bronchoscopy guidance. 1

Primary Technique: Percutaneous Dilatational Tracheostomy

PDT should be the default approach for ICU patients requiring tracheostomy, as it demonstrates shorter operative time, decreased stoma infection rates, and equivalent safety compared to open surgical tracheostomy. 1 The single dilator technique is preferred among PDT methods due to lower failure rates and fewer complications compared to other percutaneous approaches. 1

Essential Pre-Procedure Requirements

• Two physicians minimum: one operator and one assistant to manage sedation, monitor vital signs, and control the endotracheal tube 2
• Patient preparation: intubation with volume-controlled ventilation at FiO₂ = 1.0 (100% oxygen), general anesthesia with neuromuscular blockade, and neck hyperextension using a shoulder pillow 2
• Equipment: percutaneous tracheostomy kit (single dilator preferred), fiberoptic bronchoscope, and ultrasound for identifying vascular structures 2

Step-by-Step PDT Procedure

1. Identify puncture site between the 1st and 2nd tracheal rings using palpation and transillumination 2
2. Perform needle puncture under direct bronchoscopic visualization 2
3. Insert guide wire through the needle under direct visualization 2
4. Dilate the tract using single dilator technique 1, 2
5. Insert tracheostomy tube over the dilator 2

Fiberoptic bronchoscopy must be used before and during the procedure to ensure proper needle placement and prevent posterior tracheal wall injury. 2 Ultrasound guidance is optional but recommended for identifying vascular structures and optimizing puncture site selection. 2

When to Use Open Surgical Tracheostomy Instead

Switch to open surgical tracheostomy (OST) when anatomical or clinical factors make PDT unsafe or impossible. 1 These situations include:

• Absolute contraindications: skin infections at the site, prior major neck surgery 2
• Relative contraindications requiring surgical consultation: unstable cervical spine, anterior cervical infection, previous neck surgery or radiotherapy, inability to identify anatomical landmarks (obesity, short neck, thyroid hypertrophy), cervical spine stiffness, emergency situations, pediatric patients, marked anatomical deformities 1, 2
• Ultrasound findings: significant pretracheal vessels identified that cannot be avoided 1

OST Technique Considerations

When OST is chosen, perform it at the bedside in the ICU rather than the operating room to minimize transport risks and maintain negative pressure environment. 1 OST offers quicker tracheal entry without dilation and avoids bronchoscopy, but requires more healthcare workers and involves cautery with potential aerosolization. 1

Critical Safety Protocols

Operator Requirements

Only airway management physicians with extensive critical care experience should perform tracheostomy. 2 Trainees must complete 5-10 supervised procedures before independent practice, and operators need 10 procedures annually to maintain expertise. 2

Procedure Environment

• Perform in negative-pressure room in the ICU whenever possible 1
• Use enhanced personal protective equipment (PPE) as tracheostomy is an aerosol-generating procedure 1
• Minimize number of providers to the smallest experienced team possible 1
• Maintain closed ventilator circuit with in-line suction throughout the procedure 1

Modified Techniques for High-Risk Situations

For patients with coagulopathy, thrombocytopenia, or obesity, experienced teams can perform PDT using adjuncts including real-time ultrasound guidance, modified bronchoscopy techniques (scope alongside endotracheal tube with cuff inflated), or mini-surgical percutaneous approach (surgical tracheal access followed by percutaneous dilation). 1

Expected Outcomes

PDT has a mortality rate of 0.2% and major complication rate of 1.5% when performed by experienced operators. 2 The most frequent major complications are tracheal laceration, false channel insertion, and hemorrhage. 2 Neither PDT nor OST demonstrates superiority in terms of mortality or major complications, but PDT shows advantages in wound infection rates and procedural efficiency. 1

Common Pitfalls to Avoid

• Performing PDT without bronchoscopic guidance increases risk of posterior tracheal wall injury and misplacement 2
• Attempting PDT in patients with unfavorable anatomy when surgical consultation would be safer 1
• Using translaryngeal tracheotomy technique, which has higher failure and complication rates compared to other PDT methods 1
• Inadequate operator experience, as complications correlate inversely with procedural volume 2