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How a tracheostomy is performed

Surgical Anatomy

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The superior thyroid notch, cricoid and suprasternal notch usually can be easily palpated through the skin. The cricothyroid space can be identified by palpating a slight indentation immediately below the inferior edge of the thyroid cartilage. Cricothyroid arteries traverse the superior aspect of this space on each side and anastomose near the midline.

The innominate artery crosses from left to right anterior to the trachea at the superior thoracic inlet. Its pulsations can be palpated and occasionally seen in the suprasternal notch especially in case of a high riding vessel, representing a contraindication for a bedside percutaneous or open tracheostomy.

The isthmus of the thyroid gland lies across the 2nd to 4th tracheal rings and must be dealt with in any procedure at or around the upper trachea

Indications for PDT

They are the same as a routine open operative tracheostomy with particular attention to contraindications.1

Contraindications for PDT

Absolute:
Emergent tracheostomy ( i.e., securing emergent airway) in any patient population, infants and children (<15 years)

Relative Surgical Contraindications:
Poor neck landmarks, neck mass (e.g. goiter), high innominate or pulsating vessels, previous neck surgery, limited neck extension, severe coagulopathy (uncorrected)

Relative Anesthetic Contraindications:
High PEEP (>18 cm), high airway pressure (>45 cm),  high FiO2 (80%), retrognathic mandible with a limited view of the larynx on laryngoscopy

Preparation for Tracheostomy

Once the decision to perform a tracheostomy has been made, the surgeon must determine if the patient is a good candidate for the surgery and obtain written informed consent. In addition, the range of motion of the neck needs to be assessed. The tracheostomy team, including the surgeons and anesthesiologists need to discuss the entire sequence and alternatives to the procedure. All equipment must be available and functioning properly.

Equipment

A regimented approach to preparation and performance of the procedure has been shown to significantly reduce the incidence of procedural complications4.

Our approach includes the following equipment and protocols:

  • We routinely use Cook Blue Rhino single dilator kit and videobronchoscopy to perform the procedure.
  • The following must be available:
    • An attending anesthesiologist must be present for maintenance of airway, provision of intravenous sedation and performance of bronchoscopy.
    • An intubation roll and a cricoid hook.
    • Open tracheostomy set.

Technique

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Watch a tracheostomy
(24 MB Windows Media file)

The technique described here is based on Seldinger’s principle 2. The technique we use was first described and later modified by Ciaglia 3.  The use of bronchoscopy was first introduced by Marelli et al and has subsequently been adopted by many centers 4, 5.

Positioning

  1. The patient’s neck is extended over a shoulder roll (unless there is a contraindication).
  2. The anesthesiologist stands at the head end of the bed and under direct laryngoscopy positions the endotracheal tube (ETT) so that the cuff is midway at the vocal cord level.

Incision

  1. We routinely inject the skin with 1% lidocaine with 1:100,000 epinephrine solution.
  2. A horizontal or vertical incision centered on the inferior border of the cricoid cartilage may be used. We routinely use a 3-4 cm vertical incision.

Placement of Introducer Needle

  1. A minimal dissection is performed onto the pretracheal tissue in order to push the thyroid isthmus downward.
  2. The larynx is stabilized and pulled cephalad with the operator’s left hand.
  3. A bronchoscopy is then performed and the light reflex is used to select the best site for the introducer needle.
  4. Placing the needle at the inferior edge of the light reflex, the tip of the needle is directed caudad into the tracheal lumen avoiding the posterior tracheal wall at all cost.


Introduction of Guide Wire, Stylet and Initial Tract Dilatation
The needle is withdrawn while keeping the cannula in the tracheal lumen. A J-tipped guide wire is then place under vision. The stylet is then placed with the safety ridge directed towards the tip of the wire. The tract is then dilated with the 8 FR dilator.

Dilatation with the Blue Rhino Dilator
The Blue Rhino dilator is loaded on the stylet with the tip resting on the safety ridge. The dilator is moved in and out to optimally dilate the tissue between the skin and the tracheal lumen. The Blue Rhino dilator is never advanced beyond the point where 40 FR mark disappears below the skin level.

Placement of the Tracheostomy Tube

  1. A tracheostomy tube is loaded onto the dilator
    - Females: a size 6 cuffed Shiley tracheostomy tube is loaded on to the 26 FR dilator
    - Males: a size 8 cuffed Shiley tracheostomy tube is loaded on to the 28 FR dilator
  2. The dilator is then loaded on the safety ridge of the stylet and placed into the tracheal lumen under direct visualization.

Confirmation of Placement 
The bronchoscope is withdrawn from the ETT and introduced via the tracheostomy tube. The placement is confirmed by visualizing the carina.

Securing the Tube
We routinely secure the tube with 2 sutures of 2-0 nylon on each side of the flange. In addition, a tracheostomy tape is used to hold the tube in place. A flexible extension tube is used to connect the tube to the ventilator circuit to avoid undue movement of the tube in the immediate postoperative period.

Postoperative Consideration

A chest X-ray is not routinely required as long as the entire procedure was done under direct visualization and there were no adverse events intraoperatively6. The postoperative care is same as for the open procedure.

The tract between the skin and the tracheal lumen takes a little longer (10-14 days) to mature as there is no formal layer by layer dissection involved. We, therefore, perform the first tube change on Day 10-12 postoperatively.


Bibliography

  1. Goldenberg D, Bhatti .N. Management of the Impaired Airway in the Adult, in Otolaryngology: Head & Neck Surgery, Cummings CW, Editor. 2005, Mosby
  2. Seldinger, S.I., Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta Radiol, 1953. 39(5): p. 368-76.
  3. Ciaglia, P., R. Firsching, and C. Syniec, Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest, 1985. 87(6): p. 715-9.
  4. Bhatti N, Mirski M, Tatlipinar A, Koch WM, Goldenberg D. Reduction of complication rate in percutaneous dilation tracheostomies. Laryngoscope, 2007. 117(1):172-5.
  5. Marelli D, Paul A, Monilidis S, Walsh G et al. Endoscopic guided percutaneous tracheostomy: early results of a consecutive trial. J Trauma. 1990. 30(4):433-5.
  6. Hoehne F, Ozaeta M, Chung R. Routine chest X-ray after percutaneous tracheostomy is unnecessary. Am Surg, 2005. 71(1):51-3.

Tracheostomy Questions? E-mail tracheostomysupport@jhmi.edu

 

 
 

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