History

• 1.
  

  What is the nature of the current illness?

  
  
  
  
  • a.
    

    Why is the patient intubated?

    
    
  • b.
    

    What organ systems are involved?

    
    
  • c.
    

    Is there trauma to the neck?

    
    
  • d.
    

    Is the cervical spine stable?

    
    
  • e.
    

    Has the patient had a recent thoracotomy?

    
    
  • f.
    

    What is the patient’s physical status classification as per the American Society of Anesthesiology (ASA)?

    
    
  • g.
    

    Is the patient currently on anticoagulants (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], antiplatelet agents, Coumadin)?

  
  
  
  
• 2.
  

  Is tracheostomy indicated?

  
  
  
  
  • a.
    

    Expected intubation for greater than 10 days

    
    
  • b.
    

    Upper airway obstruction (e.g., trauma, neoplasms, subglottic stenosis)

    
    
  • c.
    

    Prolonged mechanical ventilation (e.g., stroke, central nervous system [CNS] disorders, respiratory failure)

    
    
  • d.
    

    Tracheobronchial toilet (e.g., chronic obstructive pulmonary disease, adult respiratory distress syndrome)

  
  
  
  
• 3.
  

  Past medical history

  
  
  
  
  • a.
    

    Previous tracheostomy

    
    
  • b.
    

    Previous surgery, radiotherapy, or trauma to the neck/cervical spine, all of which may make the procedure more difficult

    
    
  • c.
    

    Difficult or abnormal neck anatomy (e.g., kyphoscoliosis, cricoid cartilage at the sternal notch)

    
    
  • d.
    

    History of midline neck masses, high innominate artery, large thyroid gland, or goiter

    
    
  • e.
    

    Other comorbidities

    
    
  • f.
    

    Medications, in particular anticoagulants, and herbal products that affect coagulation

  
  

Physical Examination

• 1.
  

  Is the patient intubated?

  
  
• 2.
  

  Body habitus: Obesity with a body mass index (BMI) greater than 30 is more technically challenging and associated with a higher complication rate.

  
  
• 3.
  

  Neck extension: Are there limitations from anatomic abnormalities (e.g., kyphoscoliosis) or an unstable cervical spine? If so, an open ST should be performed in the OR.

  
  
• 4.
  

  Anatomic landmarks: The thyroid and cricoid cartilages as well as the sternal notch must be palpable.

  
  
• 5.
  

  Are the anatomic landmarks midline? If not, why?

  
  
• 6.
  

  A low-lying cricoid cartilage makes the procedure more technically challenging.

  
  
• 7.
  

  Are there any masses in the neck, neoplastic or otherwise, in the operative field? If so, an open ST should be performed in the OR.

  
  
• 8.
  

  A high innominate artery in or very close to the operative field is an indication for an open ST in the OR.

Imaging

• 1.
  

  A recent chest radiograph is useful in indicating a tracheal shift, lung abnormalities, or other anatomic aberrations that may affect the procedure.

Indications

• 1.
  

  Adult intubated patients in a monitored setting: ICU, coronary care unit (CCU), or postoperative recovery room

  
  
• 2.
  

  Percutaneous tracheostomy can be safely performed:

  
  
  
  
  • a.
    

    In obese patients

    
    
  • b.
    

    In patients with a prior history of tracheostomy, whether it was performed percutaneously or open

  
  

Absolute Contraindications

• 1.
  

  Inability to palpate the cricoid cartilage above the sternal notch

  
  
• 2.
  

  The presence of a midline mass in the neck (e.g., large thyroid) or goiter

  
  
• 3.
  

  A high innominate artery

  
  
• 4.
  

  Positive end-expiratory pressure requirement of greater than 15 cm H ₂ O

  
  
• 5.
  

  Children

  
  
• 6.
  

  Airway emergency, unsecured airway

Relative Contraindications

• 1.
  

  Inability to correct the International Normalized Ratio (INR) to ≤1.5

  
  

  Many ICU patients are on anticoagulants and for medical reasons cannot have their anticoagulation completely corrected preoperatively. Others have liver failure with associated coagulation defects. Percutaneous tracheostomy is the preferred procedure in these situations because of the small incision, blunt dissection, and tamponade effect of the tube.

  
  
• 2.
  

  Inability to correct the platelet count to ≥50,000

Preoperative Preparation

• 1.
  

  Comorbidities should be optimized.

  
  
• 2.
  

  Preoperative testing is minimal and includes hemoglobin levels, INR, prothrombin time, partial thromboplastin time, and platelets. INR should be corrected to ≤1.5, and platelets should be corrected to ≥50,000 functioning platelets, whenever possible. Because blood loss tends to be minimal, a preoperative crossmatch is unnecessary, unless hemoglobin levels are extremely low (≤7). Similarly, preoperative transfusions are also unnecessary, even in the presence of low hemoglobin levels.

  
  
• 3.
  

  Required personnel: surgeon, endoscopist (resident, ICU physician), nurse to administer medications, and a respiratory therapist to regulate ventilator settings

  
  
• 4.
  

  Prepare the instruments on a Mayo stand in the order in which they are to be used.

  
  
• 5.
  

  Consider the type/size of the tracheostomy tube:

  
  
  
  
  • a.
    

    For most patients a size 6 internal diameter (I.D.) tracheostomy tube with an inner cannula works well.

    
    
  • b.
    

    A size 8 I.D. tube may be necessary in patients with copious secretions.

    
    
  • c.
    

    In obese patients or those with a “deep” trachea, a proximally extended tube will prevent accidental decannulation.

  
  

Anesthesia

• 1.
  

  Intravenous sedation with or without muscle relaxants. Frequently used combinations include midazolam, fentanyl, and propofol.

  
  
• 2.
  

  Topical anesthesia: One or two milliliters of 2% to 4% lidocaine can be injected into the ETT or through the bronchoscope to suppress the cough reflex.

  
  
• 3.
  

  Local anesthesia: 1% or 2% lidocaine with 1:100,000 epinephrine is used to infiltrate the incision site to decrease cutaneous bleeding.

Positioning

• 1.
  

  Supine: The patient is positioned as for conventional tracheostomy with the neck extended.

Perioperative Antibiotic Prophylaxis

• 1.
  

  None: Within 24 to 48 hours, tracheostomy sites are colonized with a variety of organisms, including Pseudomonas, Escherichia coli, and gram-positive cocci. Tracheostomy tubes are frequently colonized by bacteria, such as Staphylococcus epidermidis, which are imbedded in a biofilm. Antibiotics do not prevent colonization and simply select out resistant organisms. Meticulous local hygiene and frequent tracheostomy tube changes control bacterial loads and provide the best defense against true infection.

Monitoring

• 1.
  

  Continuous monitoring of vital signs: particularly important in this very ill ICU patient population. Vital signs may be volatile and require pharmacologic intervention.

  
  
  
  
  • a.
    

    Heart rate

    
    
  • b.
    

    Blood pressure

    
    
  • c.
    

    Oxygen saturation

    
    
  • d.
    

    Ventilator settings are set to deliver 100% oxygen.

  
  

Instruments and Equipment to Have Available

• 1.
  

  Percutaneous tracheostomy kit: Currently, there are several kits available based on the principle of dilatation of an initial tracheal puncture. The most thoroughly evaluated kit is the Ciaglia Blue Rhino Percutaneous Introducer Kit (Cook Critical Care Inc., Bloomington, Indiana). This kit includes:

  
  
  
  
  • a.
    

    Scalpel

    
    
  • b.
    

    Introducer needle

    
    
  • c.
    

    Curved J -wire

    
    
  • d.
    

    Introducer dilator

    
    
  • e.
    

    Guiding catheter

    
    
  • f.
    

    Loading dilators

    
    
  • g.
    

    Sharply tapered single dilator

  
  
  
  
• 2.
  

  Other instruments: scalpel (if not in the kit), curved hemostat or mosquito, straight scissors, needle driver, nonresorbable sutures, water-based lubricant, a small bowl of sterile saline to activate the hydrophilic tip of the single dilator, and three 10-mL syringes.

  
  
• 3.
  

  All instruments should be placed on a Mayo stand in the order in which they are to be used.

  
  
• 4.
  

  Appropriately sized tracheostomy tube with an inner cannula. An inner cannula facilitates care and hygiene and adds an element of safety. In the event of obstruction by secretions, the inner cannula can be removed and replaced.

  
  
• 5.
  

  A proximally extended tracheostomy tube should be planned for patients with an obese neck.

  
  
• 6.
  

  Bronchoscope: preferably with a tower and screen, allowing the surgeon to visualize the intratracheal portion of the procedure. A smaller diameter or pediatric bronchoscope should be used when the ETT is ≤7.5 I.D. to allow for adequate ventilation.

  
  
• 7.
  

  Crash cart nearby with necessary equipment for intubation

Key Anatomic Landmarks

• 1.
  

  Lower border of the cricoid cartilage

  
  
• 2.
  

  Suprasternal notch

  
  
• 3.
  

  Estimate of pretracheal soft tissue thickness, especially in obese patients

Prerequisite Skills

• 1.
  

  Surgical skills

  
  
• 2.
  

  Thorough knowledge of the procedure

  
  
• 3.
  

  Having attended a training workshop

  
  
• 4.
  

  Ability to use a bronchoscope

  
  
• 5.
  

  Ability to establish an emergency airway

  
  
• 6.
  

  Ability to manage complications, such as bleeding

Operative Risks

• 1.
  

  Accidental extubation

  
  
• 2.
  

  Volatile vital signs

  
  
• 3.
  

  Bleeding

  
  
• 4.
  

  Injury to posterior esophageal wall

  
  
• 5.
  

  Creation of a false passage

Surgical Technique