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.
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.
The pretracheal tissue is cleared by blunt dissection, until the trachea is clearly palpable. It need not be fully visualized.
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.
The needle is withdrawn leaving the catheter.
A guidewire is fed through the catheter. On the bronchoscope, it should be seen going distally down the trachea towards the carina.
The catheter is removed, and the first small dilator is used to dilate the track.
The large progressive dilator is then used to further dilate the track over the extended catheter.
A tracheostomy tube with inner trocar is cannulated into the trachea over the extended catheter.
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.