Percutaneous Tracheostomy (Technique)

Percutaneous Tracheostomy (Technique)

David Ray Velez, MD

Also Known as “Perc Trach”, “Percutaneous Dilational Tracheostomy”, “PDT”, or “Modified Ciaglia Technique”

Positioning

  • Supine
  • Arms Tucked
  • Neck Extended with a Shoulder Roll Under the Shoulders (May Be Unable if in a Cervical Collar, etc.)

Identify Anatomy

  • Identify the Sternal Notch, Thyroid Cartilage, Cricoid Cartilage, and Trachea
  • Goal Location: Below the Second or Third Tracheal Rings
  • Risks of Improper Position
    • Higher: Tracheal Stenosis
    • Lower: Tracheo-Innominate Fistula

Bronchoscopy

  • Insert a Bronchoscope Through the Endotracheal Tube to Directly Visualize the Procedure
    • Generally Recommended but Not Mandatory
  • Retract the Endotracheal Tube Proximal to the Second/Third Tracheal Ring

Access the Trachea

  • 2 cm Incision (Horizontal or Vertical) About 2 Fingerbreadths Above the Sternal Notch
  • Place a Hollow-Bore Needle Through the Incision into the Trachea Under Direct Visualization Through the Bronchoscope
  • Pass a Guidewire Through the Needle and Then Remove the Needle Over the Guidewire

Tracheostomy Incision

Dilation

  • Dilate the Tract Over the Guidewire
  • First Using the Short-Dilator
  • Next Either with Multiple Serial Dilations (12-36 French) or a Single Tapered Dilator (Blue-Rhino)

Place the Tracheostomy

  • Insert the Tracheostomy Tube on an Appropriate Dilator Over the Guidewire
    • Appropriate Dilator: 20 + The Size Tube (No. 8 Tube Over a 28 F Dilator)
  • Remove the Dilator and Guidewire, Leaving the Tracheostomy Tube Intact
  • Inflate the Tracheostomy Cuff
  • Insert the Bronchoscope into the Tracheostomy Tube to Confirm Trachea Cannulation
  • Insert the Inner Cannula into the Tracheostomy Tube
  • Fully Remove the Endotracheal Tube from Above

Secure

  • Secure the Tracheostomy with a Tracheostomy Tube Holder (Strap) Around the Neck
  • Consider Securing the Tube Itself to the Skin with 2-4 Sutures
    • Use is Debated – Risk for Wound Complications but Does Not Decrease the Risk of Accidental Decannulation

Tracheostomy Dilators, Blue Rhino (Lower)