Perc Trach Step-by-Step Tutorial

Resus Review

For patients requiring prolonged mechanical ventilation a cuffed tracheostomy tube is required in place of the endotracheal tube. Traditionally this has been done with an open surgical procedure. However, a bedside procedure has been developed that allows the tracheostomy to be placed using the Seldinger technique with dilation of the dilation rather than dissection. It is formally known as a Percutaneous Dilational Tracheostomy (PDT) and can be done either with or with bronchoscopic guidance.

This is considered a minimally invasive bedside procedure that may be easily performed in the intensive care unit or at the patient’s bedside – with continuous monitoring of the patient’s vital signs.

Evaluation for Perc Trach

Two critically important preoperative criteria for PDT are:

  • The ability to hyperextend the neck
  • Presence of at least 1 cm distance between cricoid cartilage and suprasternal notch ensuring that the patient will be able to be reintubated in case of accidental extubation

Patients should not be considered for this procedure if they are:

  • Children (younger than 12 years of age)
  • Patients with severe coagulopathies
  • Patients with unidentifiable landmarks

Perc Trach Techniques

There are several different systems and approaches for PDT, but the one in most widespread use is the Ciaglia. With this technique, there is no sharp dissection involved beyond the skin incision. The patient is positioned and prepped in the same way as for the standard operative tracheostomy. General anesthesia is administered and all steps are done under bronchoscopic vision.

Advantages of Perc Trach

The procedure itself is fairly easy to learn, especially in proctored settings. Time required for performing bedside PDT is considerably shorter than that for an open tracheostomy. Elimination of scheduling difficulty associated with operating room and anesthesiology teams for critical care patients. PDT expedites the performance of the procedure because critically ill patients who would require intensive monitoring to and from the operating room need not be transported. Cost of performing PDT is roughly half that of performing open surgical tracheostomy due to the savings in operating room charges and anesthesia fees.

Procedure Steps

Step 1

The neck should be carefully palpated and all of the anatomy carefully identified (thyroid cartilage, cricoid cartilage, and 2-3 tracheal rings). The ideal location of the tracheostomy would be between the 1st and 3rd tracheal ring. Once you have identified your location, a horizontal skin incision made about 2-3 cm in length.

Percutaneous-Tracheostomy-Step1-Skin-Incision

Step 2

The pretracheal tissue is cleared by blunt dissection, until the trachea is clearly palpable. It need not be fully visualized.

Percutaneous-Tracheostomy-Step2-Dissection

Step 3

The bronchoscope is feed through the endotracheal tube but kept with the tube itself. The endotracheal tube is withdrawn until the Kelly clamp can be seen bouncing between the tracheal rings. The cuff should not be higher than the level of the glottis. A laser can be used through the surgical would to also help guide the withdrawal of the endotracheal tube.

The introducer needle is then used to puncture the anterior wall of the trachea under direct bronchoscopic visualization.

Percutaneous-Tracheostomy-Step3-Trachea-Puncture-With-Needle

Step 4

The needle is withdrawn leaving the catheter.

Percutaneous-Tracheostomy-Step4-Remove-Needle

Step 5

A guidewire is fed through the catheter. On the bronchoscope, it should be seen going distally down the trachea towards the carina.

Percutaneous-Tracheostomy-Step5-Thread-Guide-Wire

Step 6

The catheter is removed, and the first small dilator is used to dilate the track.

Percutaneous-Tracheostomy-Step6-Initial-Dilator

Step 7

The large progressive dilator is then used to further dilate the track over the extended catheter.

Percutaneous-Tracheostomy-Step7-Blue-Rhino-Dilator

Step 8

A tracheostomy tube with inner trocar is cannulated into the trachea over the extended catheter.

Percutaneous-Tracheostomy-Step8-Tracheal-Cannulation-With-Tracheostomy-Tube

The tracheostomy tube trocar, wire, and extended catheter can then be removed. The tracheostomy tube should be inflated and the inner cannula insert. You should inspect the site for any cuff leak. The bronchoscope should be removed from the endotracheal tube, and placed down the tracheostomy tube to visualize the carina. Only then should the endotracheal tube be removed.

The tracheostomy tube is secured to the skin with sutures and the tracheostomy tape.

Dont forget to document your perc trach procedure well.

Perc Trach Step-by-Step Tutorial

Perc Trach Procedure Documentation

Resus Review

Part of performing a bedside percutaneous tracheostomy is the procedural documentation. Given that this is a surgical procedure, the documentation should be more thorough than you may be accustomed to doing for an arterial line or central line.

I have included a sample procedure note below. Of course this should be adapted to the actual procedure you perform.

PERCUTANEOUS DILATIONAL TRACHEOTOMY WITH BRONCHOSCOPIC GUIDANCE

PATIENT NAME
AGE GENDER
DOB
MRN
Date of procedure

Performed by: Doctor 1, MD.
Bronchoscopy Assistant: Doctor 2, MD.
Nurse: Name, RN.
Respiratory Therapist: NAME, RT.

Indications: Chronic respiratory failure and need for ongoing mechanical ventilation.
Consent: Given patient’s intubation and sedation, the patient was unable to provide consent. Discussed the procedure with the patient’s decision maker, including the indications, risks, benefits, and alternatives. All questions were answered. Written consent was obtained and placed in the chart.
Preprocedure: Universal protocol was followed for this procedure. Prior to the initiation of sedation or the procedure, a timeout/”Pause for the Cause” was performed. The patient’s identity was verified by confirming the patient’s wrist band for name, date of birth, and medical record number. Everyone in the room was in agreement with the patient identify, the procedure to be performed, consent was in place and matched the planned procedure, and the procedure site. The area was cleaned with a CHG scrub and draped with large sterile barrier. Hand hygiene was performed, and cap, mask, sterile gown, and sterile gloves were worn. The patient was covered by a large sterile drape. Sterile technique was maintained for the entire procedure.
Anesthesia: The patient was intubated and sedated prior to the procedure. Additional midazolam and fentanyl was given for deep sedation. Please refer to the accompanying procedural sedation form for additional details. Once the patient was adequately sedated and with continuous BIS monitoring, vecuronium was administered for paralysis.
Procedure: The patient was placed in the supine position. The anterior neck was prepped and draped in usual sterile fashion. 1% lidocaine was administered approximately 2 fingerbreadths above the sternal notch for local anesthesia. A 1.5-cm horizontal incision was then performed 2 fingerbreadths above the sternal notch. Using a curved Kelly, blunt dissection was performed down to the level of the pretracheal fascia. At this point, the bronchoscope was introduced through the endotracheal tube and the trachea was properly visualized. The endotracheal tube was then gradually withdrawn within the trachea under direct bronchoscopic visualization. Proper midline position was confirmed by bouncing the needle from the tracheostomy tray over the trachea with bronchoscopic examination. The needle was advanced into the trachea and proper positioning was confirmed with direct visualization. The needle was then removed leaving a white outer cannula in position. The wire from the tracheostomy tray was then advanced through the white outer cannula. The cannula was then removed. The small, blue dilator was then advanced over the wire into the trachea. Once proper dilatation was achieved, the dilator was removed. The large, tapered dilator was then advanced over the wire into the trachea. The dilator was removed leaving the wire and white inner cannula in position. A number 6 percutaneous Shiley tracheostomy tube was then advanced over the wire and white inner cannula into the trachea. Proper positioning was confirmed with bronchoscopic visualization. The tracheostomy tube was then sutured in place with two nylon sutures. It was further secured with a tracheostomy tie.
Estimated blood loss: Less than 5 mL.
Complications: None immediate.

DOCTOR 1 NAME
Date
Pager

Perc Trach Procedure Documentation