What is the recommended procedure for performing a tracheostomy?

How to Perform a Tracheostomy

Percutaneous dilatational tracheostomy (PDT) performed at the bedside in the ICU with bronchoscopic guidance should be your default technique, as it demonstrates shorter operative time, decreased stoma infection rates, and equivalent safety compared to open surgical tracheostomy. 1

Pre-Procedure Requirements

Team Composition

• Assemble a minimum of two physicians: one operator and one assistant to manage sedation, monitor vital signs, and control the endotracheal tube 1
• Use only airway management physicians with extensive critical care experience; trainees must complete 5-10 supervised procedures before independent practice 1
• Keep the team to the least number of providers with the highest level of experience 2

Patient Preparation

• Intubate with volume-controlled ventilation at 100% oxygen 1
• Provide general anesthesia with neuromuscular blockade 1
• Position with neck hyperextension using a shoulder pillow 1
• Maintain a closed ventilator circuit with in-line suction throughout the procedure 2, 1

Equipment Setup

• Percutaneous tracheostomy kit with single dilator (preferred method due to lower failure rates) 1
• Fiberoptic bronchoscope 1
• Ultrasound machine for identifying vascular structures 1
• Enhanced personal protective equipment (PPE) for all team members 2

Location

• Perform in a negative-pressure room in the ICU whenever possible 2, 1
• If negative pressure unavailable, use a normal pressure room equipped with HEPA filters with strict door policy 2

Step-by-Step PDT Procedure

Step 1: Site Identification

• Identify the puncture site between the 1st and 2nd tracheal rings using palpation and transillumination 1
• Use ultrasound pre-procedurally to identify vascular structures and select the optimal puncture site 3

Step 2: Needle Puncture

• Perform the needle puncture under direct bronchoscopic visualization 1
• Bronchoscopy provides real-time visual guidance from within the tracheal lumen and reduces complications such as paratracheal puncture and posterior tracheal wall injury 3

Step 3: Guide Wire Insertion

• Insert the guide wire through the needle under direct visualization 1

Step 4: Tract Dilation

• Dilate the tract using the single dilator technique 1
• The single dilator method is preferred among PDT approaches due to lower failure rates and fewer complications 1

Step 5: Tube Insertion

• Insert the tracheostomy tube over the dilator 1

When to Use Open Surgical Tracheostomy Instead

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

Absolute Contraindications to PDT

• Skin infections at the puncture site 1
• Prior major neck surgery 1
• Unstable cervical spine 1
• Inability to identify anatomical landmarks 1
• Ultrasound findings of significant pretracheal vessels that cannot be avoided 2, 1

Relative Contraindications Requiring Surgical Consultation

• Anterior cervical infection 1
• Previous neck radiotherapy 1
• Cervical spine stiffness 1
• Emergency situations 1
• Pediatric patients 1
• Marked anatomical deformities 1

OST Technique Considerations

• Preferably perform at the bedside in the ICU rather than the operating room 2
• No need for bronchoscopy or access through the mouth 2
• Entry in the trachea may be quicker without need for dilation 2
• ETT cuff pushed caudally remains inflated during the incision portion, minimizing time of tracheal patency and risk of aerosolization 2

Safety Protocols to Minimize Aerosolization

Utilize techniques that minimize aerosolization, as tracheostomy is an aerosol-generating procedure that poses infection risk to healthcare workers. 2

• Use enhanced PPE for all team members (100% consensus recommendation) 2
• Consider the modified PDT technique where the ETT cuff remains inflated in the distal trachea with the bronchoscope inserted next to the ETT 2
• This modified technique may be more feasible with earlier tracheostomies before development of laryngeal edema 2
• Maintain closed circuit ventilation throughout the procedure 2

Expected Outcomes

• PDT has a mortality rate of 0.2% and major complication rate of 1.5% when performed by experienced operators 1
• Most frequent major complications: tracheal laceration, false channel insertion, and hemorrhage 1
• Mean operative time for PDT is 18.2 ± 10 minutes versus 38.2 ± 14.2 minutes for OST 4
• Neither PDT nor OST demonstrates superiority in mortality or major complications, but PDT shows advantages in wound infection rates and procedural efficiency 1

Critical Pitfalls to Avoid

• Never perform PDT without bronchoscopic guidance, as this increases risk of posterior tracheal wall injury and misplacement 1
• Do not attempt PDT in patients with unfavorable anatomy when surgical consultation would be safer 1
• Avoid the translaryngeal tracheotomy technique, which has higher failure and complication rates compared to other PDT methods 1
• Do not proceed if you lack adequate experience, as complications correlate inversely with procedural volume 1
• Never perform the procedure without ultrasound evaluation to identify pretracheal vessels 1, 3