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Tracheostomy in adults: Techniques and intraoperative complications

Tracheostomy in adults: Techniques and intraoperative complications
Literature review current through: Jan 2024.
This topic last updated: Jul 21, 2023.

INTRODUCTION — Tracheostomy is a procedure that creates an opening in the anterior wall of the trachea, through which a tracheostomy tube can be placed.

Tracheostomy can be performed as an open surgical procedure or percutaneously. An overview of the techniques involved and the intraoperative complications for both of these procedures is provided here. Indications, contraindications, non-intraoperative complications, and maintenance of tracheostomy are provided separately. (See "Tracheostomy: Rationale, indications, and contraindications" and "Tracheostomy: Postoperative care, maintenance, and complications in adults".)

TUBE TYPES — Commercially available tracheostomy tubes come in a variety of dimensions and styles. They can also be custom designed depending on factors including patient tolerance and the presence of abnormal anatomy.

Material — Tracheostomy tubes are metal or nonmetal. Metal tracheostomy tubes, which are typically made of silver or stainless steel, are rarely used in the critical care setting as they do not have cuffs allowing for mechanical ventilation. For the purposes of this topic, we are mostly discussing nonmetal tracheostomy tubes, which are typically made of polyvinyl chloride (PVC), silicone, or polyurethane.

Nonmetal – Nonmetal tracheostomy tubes are cheaper than metal tubes. They are less rigid and more likely to conform to the airway shape; for example, PVC softens at body temperature, while silicone is naturally soft. Nonmetal tracheostomy tubes, unlike metal tracheostomy tubes, typically have an inflatable cuff and a universal adapter that attaches to ventilator tubing (typically a 15 mm connector). Sterilization is not necessary since they are generally replaced every six to eight weeks. Choosing the right one with the best fit is important for tolerance. (See 'Selecting a tracheostomy tube' below.)

Metal – Metal tubes are not used commonly since they are expensive, rigid, and do not have a cuff or a universal adapter that connects to a ventilator. Therefore, they cannot be used in patients who require positive pressure ventilation. Metal tracheostomy tubes are durable, more resistant to infection than nonmetal tracheostomy tubes, easy to clean, and can be repeatedly sterilized by autoclaving for reuse in the same patient. They may be suitable for life-long use in patients who have good pulmonary reserve and do not need ventilation (eg, following laryngectomy due to cancer or trauma).

Hybrid – Some hybrid designs combine "super-pliable" material with metal spiral wire-reinforcement to enhance airway comfort and conformation.

Components — Components of a nonmetal tracheostomy tube include the following (picture 1 and picture 2):

The connector/adapter, which connects the tracheostomy tube with the ventilator (if needed). For some tracheostomy tubes, the connector is part of the inner cannula.

The flange (typically between the connector and the shaft), which has side holes for tracheostomy ties to secure the tracheostomy tube to the neck.

The shaft, which leads from the connector to the distal tip; the shaft is generally acutely angled or gently curved to accommodate its position proximally in the neck/trachea; the distal tip is usually tapered for easy insertion.

The cuff (located just above the distal tip), which is inflated using a pilot balloon served by a one-way valve (similar to that on an endotracheal tube [ETT]). Some tracheostomy tubes are cuffless. (See 'Fenestrated/nonfenestrated, cuffed/uncuffed' below.)

An inner solid trocar (also known as obturator) with a smooth, rounded, tapered distal end, which aids placement/replacement and should be removed once the tracheostomy tube is in place.

Single cannula, dual cannula — Tracheostomy tubes can have a single lumen (ie, single-cannula tracheostomy tube) or have an inner cannula (dual-cannula tracheostomy tube). The inner cannula is a narrower hollow cannula of the same length and shape as the tracheostomy itself and lies inside the main lumen of the tracheostomy tube (ie, a patent tube inside another patent tube (picture 1)).

The main advantage of an inner cannula is that it can be easily removed and cleaned regularly without removing the tracheostomy tube from its stoma, so the airway remains intact and stable.

It is prudent that the clinician be familiar with the structure of an existing tracheostomy. For example, when tracheostomy tubes are used for mechanical ventilation, the inner cannula, due to its narrow lumen, can increase airway resistance and thereby increase the work of breathing. Thus, in many cases, the inner cannula can be removed during ventilation or bronchoscopy [1]. However, sometimes the ventilator adapter is on the inner cannula, and the ventilator cannot be attached unless the inner cannula is in place, making passage of a bronchoscope a challenge (particularly a large therapeutic bronchoscope). (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Entering the tracheobronchial tree'.)

Dimensions and shape — The dimensions of tracheostomy tubes are measured in millimeters and include the following:

Inner and outer diameter – For single-cannula tracheostomy tubes, the inner and outer diameter refer to the diameter of the tracheostomy tube at its smallest and widest dimensions, respectively (picture 3). The inner diameter roughly correlates with that used to describe the diameter of ETT. For example, a size 7 ETT approximates a size 7 tracheostomy tube and has an inner diameter of 7 mm.

For dual-lumen tracheostomy tubes, an inner and outer diameter is also provided for the inner cannula. It is important to note that although a tracheostomy tube may be listed as, for example, a size 7, the actual inner diameter may be smaller than 7 mm when the inner cannula is in place (eg, 6 mm). Further complicating matters, not all commercially available products adhere to these rules. Thus, it behooves the clinician to familiarize themselves with the measured diameters provided by manufacturers on the packaging and flange of the device.

Length – This refers to the entire length of the tracheostomy tube from the adapter to the distal tip. Tracheostomy tube length varies to accommodate tracheas that are long or short in length (eg, 65 to 120 mm). Some tracheostomy tubes also have an adjustable flange for the purpose of lengthening or shortening the tube so that a good fit can be achieved.

Shape – The shaft of tracheostomy tubes can be angled or curved (picture 4). Both are designed to accommodate the tract along which the tube lies; the initial portion of the tracheostomy tract is curved/angled, while the tracheal portion is straight. In angled tubes, the angle is generally acute, and the shaft is straight, while curved tubes are gently curved throughout. In theory, angled tubes may better conform to the shape of the tract, while curved tubes may increase the risk of posterior wall injury. While angled tracheostomy tubes are generally preferred, this selection is at the discretion of the surgeon or proceduralist.

All dimensions can be found on the packaging and on the flange of the tracheostomy tube. Importantly, tubes of the same dimensions vary among manufacturers and may therefore look and feel differently to individual patients. This is particularly important for clinicians when exchanging a tracheostomy tube rather than during initial selection. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Changing a tracheostomy tube'.)

Fenestrated/nonfenestrated, cuffed/uncuffed — Most tracheostomy tubes are nonfenestrated (picture 5) and have an inflatable cuff, although variations exist. When mechanical ventilation is necessary via a tracheostomy tube, a nonfenestrated tracheostomy tube and an inflated cuff is mandatory to prevent air leak and ensure delivery of a set tidal volume or pressure.

Fenestrations – Some tracheostomy tubes are fenestrated along their shaft. Fenestrations can be single or multiple and are located above the cuff. Fenestrated tracheostomy tubes are being used less frequently since they may be associated with granulation tissue formation, possibly due to turbulent flow through the fenestration onto the tracheal wall [2].

While the cuff is inflated, fenestrations allow air to flow around the tracheostomy tube, thereby promoting respiration and phonation through the vocal cords and upper airway; by contrast, in a nonfenestrated tube, the cuff needs to be deflated for this to occur. This is more relevant for weaning and preparing for decannulation. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Decannulation'.)

Of note, an inner cannula will block fenestrations unless the inner cannula is also fenestrated. (See 'Single cannula, dual cannula' above.)

Cuffs – While most tracheostomy tubes have an inflatable cuff, some do not. Similar to fenestrations, the absence of a cuff allows air to move around the tube, thereby facilitating phonation and respiration through the vocal cords. An inflated cuff, in theory, may help protect against aspiration of secretions, although this is an unproven benefit of cuffed tracheostomy tubes. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Aspiration and nosocomial pneumonia'.)

High-volume-low-pressure cuffs are typically used and are usually inflated with either sterile water or air. However, some cuffs are comprised of a "foam"-like material when inflated.

All cuffs are designed to obtain a tight seal while also limiting pressure on the tracheal wall (eg, 20 to 30 cm H2O), reducing the risk of complications related to hyperinflation, including tracheal stenosis and/or tracheomalacia, necrosis with perforation of the tracheal wall, or tracheal fistulas. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Maintain optimal cuff pressure'.)

Some cuffed tracheostomy tubes have a subglottic port just cephalad (ie, superior) to the cuff for suctioning secretions. Their value in the prevention of infection is unclear.

PREOPERATIVE ASSESSMENT — Once tracheostomy is indicated, we assess the patient for safety of the procedure and select a suitable tracheostomy tube and approach.

General — The components of preoperative assessment for patients undergoing tracheostomy are discussed separately. (See "Anesthesia for tracheostomy", section on 'Preoperative assessment'.)

Selecting percutaneous versus operative — Once the decision has been made to place a tracheostomy tube, an approach needs to be selected. For many years, surgical (open) tracheostomy was the only option. However, bedside percutaneous tracheostomy is being increasingly used since the late 1990s and has become a successful alternative to surgical tracheostomy in many patients [3]. Specific training is required for proficiency in both techniques.

This section describes how to choose between an open and a percutaneous approach. Indications for tracheostomy are discussed separately. (See "Tracheostomy: Rationale, indications, and contraindications".)

Factors influencing the choice — Choosing between surgical or percutaneous tracheostomy depends upon several factors, including the following:

Institutional expertise – Percutaneous tracheostomy is a relatively new technique requiring a different skill set to surgical tracheostomy. Percutaneous tracheostomy is generally performed by surgeons, interventional pulmonologists, or intensivists [4,5].

Select conditions – Surgical approach may be preferred in patients with features listed on the table (table 1). Contraindications for both surgical and percutaneous tracheostomies include:

Uncorrectable bleeding diathesis (eg, International Normalized Ratio >2.0, platelets <50,000 x 109/L).

Hemodynamic instability.

Severe hypoxemia (eg, fraction of inspired oxygen [FiO2] >0.6 and/or positive end expiratory pressure [PEEP] >12 cm H2O).

However, the boundaries of what is considered a relative contraindication for percutaneous tracheostomy are constantly being challenged as experience improves and the technique is refined. For example:

Percutaneous tracheostomy has been successfully performed in older patients (eg, >80 years), patients who have grade 3 obesity, and patients with a history of previous tracheostomy or with thrombocytopenia following preprocedure platelet transfusion [6-9].

Successful percutaneous tracheostomy has also been reported in patients receiving PEEP >12 cm H2O, high-frequency oscillation ventilation, or extracorporeal membrane oxygenation, although complication rates may be higher [10-12]. In patients requiring high levels of PEEP, we sometimes try increasing the FiO2 and reducing PEEP to <10 cm H2O to assess "PEEP dependency," and if the patient becomes hypoxemic, surgical tracheostomy may be a better option.

The rationale for this approach is that in the majority of percutaneous tracheostomies, the stoma is created caudal (ie, distal) to the tip of the endotracheal tube (ETT), resulting in derecruitment and ensuing hypoxemia. This is in contrast to a surgical tracheostomy, where the stoma is created cephalad (ie, proximal) to the cuff of the ETT such that derecruitment is unlikely to occur. A newer bronchoscopic approach for guidance during percutaneous tracheostomy to avoid derecruitment has also been described. (See 'Variants' below.)

Limited data suggest that percutaneous tracheostomy may be safely performed in patients taking antiplatelet therapy. Several retrospective studies of patients on single or dual antiplatelet therapy who underwent percutaneous tracheostomy reported no convincing increase in the rate of bleeding compared with patients who were not on antiplatelet therapy [13-15].

Advantages and disadvantages of percutaneous tracheostomy — There are several advantages and disadvantages of percutaneous compared with surgical tracheostomy:

Advantages – Unlike surgical tracheostomy, percutaneous tracheostomy can be performed bedside. In addition, it requires less time to perform [16], is less expensive [16], and is typically performed sooner (because an operating room does not have to be scheduled) [17-19]. In addition, some complications may be less frequent with percutaneous tracheostomy than surgical tracheostomy (eg, bleeding and infection), although the quality of the data is poor [18,20-27]. Complications are discussed separately. (See 'Intraoperative complications' below and "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Complications'.)

Disadvantages – Percutaneous tracheostomy may have an increased risk of anterior tracheal injury (eg, ring fractures) and posterior tracheal wall perforation (figure 1) [28]. In addition, it has several relative contraindications compared with the surgical approach (table 1). (See 'Factors influencing the choice' above.)

Selecting a tracheostomy tube — When initially selecting a tracheostomy tube, no one size fits all, and the process is generally at the discretion of the operating surgeon or proceduralist.

We take the following factors into consideration:

Patient age, weight, and height

Neck and tracheal size

Tracheal pathology (eg, tracheomalacia, distorted trachea)

The main purpose for tracheostomy (eg, airway secretion clearance, ventilation, weaning, phonation)

For initial selection in most patients, we use a standard commercially available, rather than a customized, tracheostomy tube. As examples:

For patients undergoing ventilator weaning with a view to decannulation, we generally select a size 6 to 8 nonfenestrated, cuffed tracheostomy tube.

For patients with other indications including those who need airway access for secretion clearance and upper airway obstruction, a nonfenestrated, cuffed or cuffless tracheostomy tube is also appropriate.

Decisions then need to be made regarding the dimensions. A few examples of how a clinician might select an appropriate tube size are given below, but ultimately the tracheostomy tube can be easily changed at a later date to improve comfort and fit as the patients' needs evolve. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Changing a tracheostomy tube'.)

Diameter – For adult patients who are underweight, young in age, or have a small body habitus, smaller tubes are generally selected (eg, a size 4 or 6 tracheostomy tube). For patients who may need bronchoscopy in the future (eg, obstructing tumors), a tracheostomy tube that can accommodate a diagnostic or therapeutic bronchoscope should be considered (eg, size 8). Males can generally also tolerate larger tubes compared with females since they have a larger airway diameter.

Appropriate diameter is important to maintain a good seal and minimize airway resistance and work of breathing. For example, when the inner diameter is too small, higher cuff pressures are generally needed to maintain a tight seal, thereby increasing the risk of tracheal injury and stenosis; in addition, airway resistance will be increased, thereby increasing the work of breathing, which may interfere with ventilator weaning. When the tracheostomy tube is too large in diameter, a fully inflated cuff will also result in increased tracheal wall pressure and therefore, increase the risk of stenosis. (See "Presentation and diagnostic evaluation of non-life-threatening and nonmalignant subglottic and tracheal stenosis in adults".)

Length – Appropriate length is also important for comfort, fit, and final position of the tracheostomy tube within the tracheal lumen. Most tracheostomy tubes come as a "standard" length (eg, 60 to 65 mm targeted at 4 to 6 cm above the carina), although what is considered "standard" varies among manufacturers.

Patients who have thick anterior neck wall due to anatomical structures or obesity (distance from skin to trachea >4.4 cm) might benefit from an extended proximal tracheostomy (eg, extra-long tracheostomy tube [XLT] proximal tracheostomy (picture 6)) [29]. Selecting a shorter tracheostomy tube could potentially lead to placement of the cuff in the stoma resulting in inadequate ventilation with air leak, high cuff pressures, and malposition of the distal opening of the tracheotomy; the latter can lead to formation of granulation tissue or to obstruction of the lumen by the posterior tracheal wall.

Tall individuals, as well as patients who have focal tracheomalacia, tracheoesophageal fistulas, or tumors located in the mid-trachea, may be considered for an extended distal length (eg, XLT distal tracheostomy (picture 6)), with the main goal of bypassing these structural abnormalities, and/or proper alignment of the tracheostomy tube in the center of the tracheal lumen. During placement of XLTs, we typically confirm bronchoscopically that the distal opening of the tracheostomy is located approximately 2 cm above the carina and not in the right or left main stem bronchus.

Dual or single cannula – For patients with tenacious secretions, we generally use a single-lumen tracheostomy tube, or, alternatively, a dual-lumen tracheostomy tube with the inner cannula removed to facilitate airway clearance. (See 'Single cannula, dual cannula' above.)

Others – Tracheostomy tubes with wire reinforcement are not suitable for patients who need to undergo therapy with laser or electrosurgical devices or need magnetic resonance imaging.

TRACHEOSTOMY TECHNIQUES — The elective placement of a tracheostomy tube is described here. Performance of an emergent cricothyrotomy is described separately. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults" and "Needle cricothyroidotomy with percutaneous transtracheal ventilation".)

Anatomic location — Most tracheostomies should be placed between the second and third tracheal rings, provided it is feasible. Tracheostomy placement below this level increases the risk of innominate artery bleeding (which can be catastrophic), while placement above the first ring increases the risk of subglottic stenosis.

For all patients, but particularly those at risk of complications and those undergoing percutaneous tracheostomy, we use bedside ultrasound to identify vascular and other anatomical structures (thyroid, tracheal rings, etc) and to confirm feasibility and safety of the percutaneous approach (image 1) [30]. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Tracheal and stoma stenosis' and "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Tracheoesophageal fistula'.)

Checklists, medication adjustment, infection control, cuff inflation — For patients undergoing tracheostomy, we use a checklist to reduce the risk of procedural complications [31]. We ensure that all necessary equipment, including an airway cart as a back-up in the event of airway loss, and staff are present for the intended procedure. (See 'Surgical (open)' below and 'Percutaneous' below.)

We generally hold anticoagulants the day of the procedure, according to general guidelines for airway procedures [32]. As examples:

If patients require heparin (eg, are receiving extracorporeal membrane oxygenation [ECMO]) or direct oral anticoagulants, we ideally hold anticoagulation four hours pre- and two hours post-procedure. Communication with the ECMO and intensive care unit (ICU) teams is essential. Warfarin may need to be held for longer or reversed with fresh frozen plasma to target an International Normalized Ratio <1.5. (See "Perioperative management of patients receiving anticoagulants".)

We generally continue aspirin and deep vein thrombosis prophylaxis.

We hold dual antiplatelet agents (eg, clopidogrel) for five days prior to the procedure; if this is not feasible, we identify vascular structures and the thyroid isthmus with ultrasound in advance of the procedure to minimize bleeding complications.

Data to support this practice are limited. One retrospective cohort study of 34 patients receiving dual antiplatelet and anticoagulation therapy reported that percutaneous tracheostomy was not associated with severe or potentially life-threatening procedure-related bleeding [33].

Since tracheostomy is an aerosol-generating procedure, for patients in whom aerosolization of infectious secretions is a concern, full personal protective equipment (PPE) should be worn and the procedure performed under airborne isolation conditions (ie, a "negative-pressure" room). (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

For cuffed tracheostomies, we confirm proper inflation of the cuff and demonstrate no air leak by insertion of the inflated cuff into sterile saline, to reduce the risk ventilatory failure and/or emergent airway loss immediately after insertion.

Surgical (open)

Equipment — Equipment required for an open tracheostomy includes the following:

The tracheostomy tube of choice, typically a cuffed, nonfenestrated device of a designated size, plus one a size above and one a size below the chosen device. (See 'Tube types' above and 'Selecting a tracheostomy tube' above.)

A tracheostomy collar and soft ties.

Scalpel (eg, number 15 surgical blade).

Dissecting tools (eg, forceps or curved hemostat).

Suture kit.

Gauze.

Electrocautery.

Sterile gown and gloves and other necessary PPE (eg, shield, goggles) when aerosolized infectious precautions are required.

An end-tidal carbon dioxide (CO2) monitor.

Intubation tray (in event of airway loss).

Ultrasonography and bronchoscopy may be needed to identify the correct anatomic location for device insertion and to verify the correct position after placement, respectively.

Personnel — In general, a surgeon, surgical assistant, anesthesiologist, and scrub technician are present for the procedure.

Procedure — Elective, open, surgical tracheostomy is most often performed under general anesthesia in the operating room (OR), although occasionally, it can be performed under local anesthesia (eg, submandibular space infections). The patient is supine with the neck extended by placing a small shoulder roll beneath the scapulae and the head supported by a small pillow. Details regarding patient preparation and anesthesia during tracheostomy are provided separately. (See "Anesthesia for tracheostomy".)

Following a time-out for patient- and procedure-related identification, the approach is as follows:

The thyroid notch, cricoid cartilage, and sternal notch are identified by palpation and/or ultrasound and marked (figure 2).

The area is palpated for a high-riding innominate artery that may underlie the incision site.

The proposed skin incision line (typically horizontal or longitudinal "H-shaped") is marked 1 to 2 cm inferior to the cricoid cartilage.

After sterilization of the skin, the anterior neck is draped.

An incision is made through the skin and platysma muscle.

The sternohyoid and sternothyroid muscles are retracted laterally to expose the cricoid cartilage and thyroid gland (figure 3).

The thyroid isthmus is identified and ligated, if necessary, depending on its location along the trachea.

We re-examine for the possibility of a high-riding innominate artery which, in a small proportion of patients, can course along the anterior trachea and retract inferiorly once divided. If present, it should be ligated.

A cricoid hook is then placed under the cricoid cartilage to elevate the larynx and trachea into the operative field.

An incision is made between the second and third tracheal rings (ie, above the cuff of the endotracheal tube [ETT]).

The ETT cuff is deflated and pulled back slightly, by the anesthesiologist.

The tracheostomy tube is placed through the incision.

The tracheostomy cuff is inflated and tracheostomy tube connected to the ventilator/anesthesia circuit. Capnography should be used to confirm airway placement. It is good practice to also check for subcutaneous emphysema.

The ETT can then be removed.

The cricoid hook is removed and the tracheostomy tube secured to the neck with soft transcervical ties that attach through the flange (ie, a tracheostomy collar). We generally do not suture the tracheostomy to the skin of the neck since this has not been proven to result in a reduction in accidental decannulation. However, some surgeons still perform this maneuver, especially if the staff is unfamiliar with tracheostomy care. Regardless of the mechanism used to secure the tracheostomy, it should not be too tight or too loose (approximately one finger's width between suture/tie and the neck).

A skin protector (eg, sterile gauze) is placed around the tracheostomy and underneath the flange of the tracheostomy tube and ties to protect the skin from erosion.

We perform bronchoscopy to ensure location of the device at least 2 cm above the carina and remove any secretions that remain in the airway following the procedure.

Percutaneous — Percutaneous tracheostomy is generally performed at the bedside in the ICU but can be performed in the OR, especially if the patient is thought to be at risk of complications or conversion to an open approach (eg, patients at risk of bleeding that may need electrocautery, which is not typically available in the ICU). The procedure is generally performed under sedation and paralysis (preferably a short-acting neuromuscular blocker). (See "Clinical use of neuromuscular blocking agents in anesthesia" and "Neuromuscular blocking agents in critically ill patients: Use, agent selection, administration, and adverse effects", section on 'Clinical use'.)

Equipment and personnel — Equipment and personnel differ slightly from the surgical approach.

Equipment – The equipment and infectious precautions are similar to that required for an open tracheostomy (see 'Equipment' above), with additional need for the following:

All equipment (including ultrasound machine) should be confirmed to be available in the room. Percutaneous tracheostomy kits are commercially available. They usually contain a scalpel, introducer needle and syringe, guidewire, tracheal dilators (small dilator and single tapered dilator), protective sheath, and tracheal loading trocar (picture 7). Although many kits come with a loading mechanism for an included tracheostomy, any tracheostomy can be used. Most commercially available dilator kits employ a single tapered dilator that decreases procedure time and does not differ in the incidence of complications when compared with a multiple progressive dilator technique [34].

All medications (sedatives, vasopressors, neuromuscular blockage agents) should be available and ready for administration. We prefer deep sedation be achieved before the procedure. (See "Sedative-analgesia in ventilated adults: Management strategies, agent selection, monitoring, and withdrawal".)

We ensure an airway back-up plan, in the rare event of airway loss. Thus, the following items should be available (see 'Loss of the airway' below and 'Procedure' below):

-An Ambu bag connected to the oxygen supply with a positive end expiratory pressure (PEEP) valve (at head of the bed)

-An appropriate-sized oral airway (at head of the bed)

-A suction device (at head of the bed)

-An airway cart with ETTs and video laryngoscope (available inside or outside the room)

A bronchoscope is needed along with an adaptor for the ventilator, water-based lubricant, and sterile saline. We prefer a video bronchoscope with the screen preferably located in a position where both the operator and the bronchoscopist can easily visualize the airway relative to the tracheostomy insertion site. (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications".)

Blunt dissection instruments for tracheal exposure.

An end-tidal CO2 monitor is suggested since respiratory acidosis is more likely to occur during percutaneous than surgical tracheostomy, especially in patients with brain-injury [35].

Personnel – Percutaneous tracheostomy is generally performed by surgeons, interventional pulmonologists, or critical care clinicians who are trained in the procedure [4,5].

Two clinicians are required, one to perform the percutaneous procedure at the neck and one to perform bronchoscopy via the ETT so that the passage of the wire, dilators, and tracheostomy tube into the trachea can be directly visualized.

In addition, a nurse and respiratory therapist are required to facilitate monitoring and administration of sedating medications and manage the ventilator and ETT, respectively.

Procedure — Following a time-out for patient- and procedure-related identification, the patient is positioned supine with the neck extended by placing a small shoulder roll beneath the scapulae and the head supported by a small pillow. The patient should be monitored with telemetry continuously, blood pressure checked every two minutes, and an oximeter (preferably and audible device) in the contralateral upper extremity. Additionally, the bed should have all four bed rails down and headboard removed to ensure full access to the patient and equipment.

The patient is sedated appropriately and the ventilator settings adjusted to provide audible alarms for high airway pressure and fraction of inspired oxygen at 1.0. Before a bronchoscopy adaptor is attached to the ETT, we typically suction with a closed-circuit system tubing.

We prefer percutaneous tracheostomy using a tapered dilator approach (ie, Ciaglia technique), since it is superior to other percutaneous approaches including the single-forceps (Griggs) technique [36-38].

The initial approach to clean the skin, drape, and expose the trachea is similar to that described for the surgical approach (see 'Procedure' above), except we typically make a 1.5 to 2 cm vertical incision through the skin since the anterior jugular veins run vertically and lateral to the midline. It has also been suggested that a horizontal incision may be associated with fewer stoma ulcerations when compared with vertical incisions [39]. We also typically locally infiltrate the area with lidocaine and epinephrine, although this is not always universally performed.

If there is a risk of bleeding (eg, from coagulopathy), some experts place a purse-string suture around the incision site and leave it untied for use in the event of bleeding.

If the tracheal rings are not palpable, then pretracheal tissue is bluntly dissected until the trachea is digitally palpable (figure 3).

The bronchoscope is then introduced into the ETT, minimizing suction (too much negative suction may theoretically mitigate PEEP).

The tip of the bronchoscope is aligned with the caudal (ie, distal) tip of the ETT (picture 8).

The bronchoscopist remains in the same position ("locked" position) at the ETT tip while providing full visualization of the tracheal lumen. The cuff of the ETT is deflated and the respiratory therapist along with the bronchoscopist slowly withdraw the ETT to the proximal end of the trachea (ie, the subglottic area (picture 9)), at which point, the cuff is then reinflated. The surgeon/operator can palpate the subglottic area or use transillumination with the bronchoscopy light to facilitate the identification of this landmark. In patients who are very PEEP dependent, we typically pull the ETT back with the cuff inflated to avoid derecruitment.

The tip of both the ETT and the bronchoscope provides a good field of view within the tracheal lumen, which avoids cuff disruption by the introducer needle. Avoidance of cuff disruption is critical in the event that a complication occurs necessitating rapid replacement of the ETT and resumption of mechanical ventilation. During local infiltration, the 25 gauge needle used can be visualized by the bronchoscope.

Under direct bronchoscopic visualization, the needle used to deploy local anesthetic can be easily seen and is withdrawn (picture 10), and the introducer needle, which also includes a catheter, is inserted perpendicular to the trachea through the anterior wall typically between the second and third cartilage rings. Once in the airway, while maintaining a centered position in the lumen, the needle is angled caudally and removed, leaving the plastic catheter in place (picture 11 and picture 12).

The guidewire is fed through the catheter and follows a caudal (distal) course into the trachea towards the carina, which is confirmed visually by the bronchoscopist (picture 13).

The introducer catheter is removed and a small punch dilator is placed over the guidewire using the modified Seldinger technique, ensuring that the wire is visualized on both ends of the dilator before advancing it through the tracheal wall and all the way to the hub. The dilator is then removed, while keeping the guidewire in place (picture 14).

With the protective guide catheter loaded, the single-stage progressive dilator is advanced over the guidewire along the dilated tract using the same modified Seldinger technique (picture 15 and picture 16). The dilator is then removed, keeping the guide catheter and wire in place.

The loading dilator, which has been inserted into the tracheostomy (in advance) is placed over the guide catheter/guidewire into the trachea (picture 17).

The wire, guide catheter, and loading dilator are removed and the tracheostomy is left in place. The cuff is inflated (picture 18).

We perform bronchoscopy via the new tracheostomy tube to confirm appropriate airway placement and location from the carina (picture 19). Once confirmed, the ventilator circuit is disconnected from the ETT and attached to the tracheostomy. We additionally use end-tidal CO2 monitoring and confirmation of returned tidal volumes to confirm airway placement. (See "Carbon dioxide monitoring (capnography)".)

The tracheostomy tube is secured to the neck with soft ties (ie, a tracheostomy collar). We generally do not suture the tracheostomy to the skin of the neck, although some experts still perform this maneuver, especially if the staff is unfamiliar with tracheostomy care. Sterile gauze is placed underneath the flange to prevent skin ulceration.

After ensuring airway placement, the ETT cuff can be deflated, and the ETT can be removed and discarded.

Variants — Several variants of the single-dilator technique have been described:

Bronchoscopic – A newer bronchoscopic approach for guidance during percutaneous tracheostomy to avoid derecruitment has been described. In this technique, the existent ETT is advanced caudally (distally) into the trachea, and a bronchoscope is inserted parallel and external to the ETT, allowing full visualization of the anterior aspect of the proximal trachea, while keeping the ETT cuff fully inflated, thereby, avoiding loss of PEEP [40].

Ultrasound – Percutaneous tracheotomy is less frequently performed under ultrasound guidance by interventional radiologists in the radiology suite. Ultrasound with a sterile cover for the probe is used to locate the landmarks and tracheal rings, and direct laryngoscopy is used to withdraw the ETT. Otherwise, the procedure is similar to that described above. (See 'Procedure' above.)

Experience and data are limited with this approach [24,41-43], although one meta-analysis of four retrospective studies suggests no difference in outcomes when landmarks were identified using bronchoscopic compared with ultrasound guidance [43]. However, bronchoscopy is preferred by the vast majority of proceduralists, as it allows the operator to avoid posterior tracheal injury, and to ensure proper location and midline initial needle insertion as well as facilitate aspiration of secretions and confirm that the distal tip of the tracheostomy is both above the carina and centered in the tracheal lumen.

Balloon-dilation – A balloon-dilation method has also been described [44]; however, comparative efficacy trials with the single-dilator technique described in this topic have not been performed.

COVID-19 — Both open and percutaneous tracheostomy procedures are acceptable in coronavirus disease 2019 (COVID-19) patients. (See 'Selecting percutaneous versus operative' above.)

Tracheostomy is considered a high-risk procedure for aerosolization. For patients who remain infectious at the time of the procedure, we prefer that tracheostomy be done at the bedside in an airborne isolation room with the minimum number of personnel present. All individuals should wear appropriate PPE. We typically use deep sedation or neuromuscular blockade (to minimize cough) and ensure that the tracheostomy tube has the syringe attached for immediate balloon inflation once inserted. In addition, adapters with inline suction catheters should be immediately attached after insertion. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Novel barrier protections for performing tracheostomy have been proposed but are not routinely used. In one report, tracheostomy was performed under an aerosol-reduction cover with a high-efficiency particulate air filtration unit placed close to the surgical field [45]. However, no description of aerosol deposition was provided.

INTRAOPERATIVE COMPLICATIONS — In general, major complications from tracheostomy are infrequent and death is rare. Intraoperative complications include bleeding, pneumothorax/pneumomediastinum, posterior wall perforation, tracheal ring fractures, and airway loss or fire [46,47].

Early postoperative and long-term complications are discussed separately. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Early (within 7 to 10 days)' and "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Late (≥7 to 10 days)'.)

Bleeding — Bleeding is the most common intraoperative complication, especially when a bleeding diathesis is present. One study reported that bleeding complications could be predicted by a platelet count less than 50 x 109/L, an activated partial thromboplastin time longer than 50 seconds, or the presence of two or more coagulation disorders [48]. Administration of prophylactic subcutaneous heparin did not increase the risk of bleeding.

Bleeding may be less commonly encountered during percutaneous compared with surgical tracheostomy, since blood vessels are compressed during percutaneous tracheostomy rather than ligated or cauterized. Additional data describing the postoperative risk of bleeding are provided separately. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Bleeding'.)

Intraoperative bleeding may be minimized by the transfusion of blood products to correct a coagulopathy (eg, fresh frozen plasma, platelets), by paying careful attention to the anatomy (image 1), and ensuring that the tracheostomy tube is not placed below the second or third tracheal ring, which increases the risk of an innominate artery bleed (see 'Anatomic location' above). In addition, the majority of bleeding is due to superficial skin vessels; using lidocaine with 1.5% epinephrine and a small incision ensures that the tracheostomy tube itself tamponades the vessels and minimizes the risk of bleeding.

Pneumothorax/pneumomediastinum from a false tract — Pneumothorax or pneumomediastinum can occur if the tracheostomy tube is placed into a false passage anterior to the trachea rather than the lumen of the trachea itself. Pneumothorax or pneumomediastinum can also occur if the guidewire punctures the posterior or lateral wall of the trachea during placement of a percutaneous tracheostomy.

If suspected, a chest radiograph should be obtained and a chest tube placed, if indicated. If confirmed, the tracheostomy tube should be removed, ventilation continued via the endotracheal tube (ETT), and further attempts made to appropriately place the tracheostomy tube in the airway. (See "Diagnosis, management, and prevention of pulmonary barotrauma during invasive mechanical ventilation in adults", section on 'Barotrauma diagnosis and management'.)

Paying attention to landmarks and ensuring airway placement with capnography or fiberoptic endoscopy should help with the early detection of this potential complication.

Esophageal perforation — Perforation of the posterior wall of the trachea through to the esophagus is rare [49].

The risk of this complication can be reduced by directing the bevel of the of the introducer needle and dilators caudally (distally) during insertion along with direct observation that the guidewire appropriately migrates towards the carina (picture 11 and picture 12 and picture 13). (See 'Percutaneous' above and 'Factors influencing the choice' above.)

Percutaneous tracheostomy is also typically avoided in children, in part for this reason.

Tracheal ring fractures — Tracheal ring fractures are more likely to occur during percutaneous than surgical tracheostomy due to pressure exerted onto the trachea from repetitive dilation [50-52]. However, the clinical significance is uncertain.

Rates vary among studies (3 to 36 percent) [50-52]. Close or calcified tracheal rings may increase the risk, while careful dilatation during percutaneous tracheostomy should decrease the risk.

Fractures generally do not require therapy unless they are displaced or result in significant malacia, in which case surgical resection may be required.

Loss of the airway — Accidental extubation is a complication of both surgical and percutaneous tracheostomy, but it is more likely to occur with the percutaneous approach. During percutaneous tracheostomy, airway loss can occur when the patient is not adequately paralyzed and coughs during the procedure or when communication between the surgeon, respiratory therapist, and bronchoscopist is inadequate.

Loss of the airway is potentially catastrophic and can be minimized by adequate paralysis, good communication strategies among staff, and maintenance of cuff integrity in the event that ventilation needs to be resumed. (See 'Procedure' above.)

If the airway is lost, a new one should be created either by reintubating the patient with a new ETT and/or completing the tracheostomy, whichever option is quicker. An advantage of using bronchoscopic guidance is that if the patient is accidentally extubated, the bronchoscope can be advanced and the ETT reinserted into the trachea over the bronchoscope.

Airway fire — Airway fire is a rare complication that occurs from combustion of oxygen by the electrocautery unit during open surgical tracheostomy. It is more likely in those needing high fractions of inspired oxygen [47].

This complication can be minimized by good communication between the anesthesiologist and surgeon when electrocautery is being used.

In the event of airway fire, the patients should be disconnected from the anesthesia circuit and undergo bag ventilation until the tracheostomy is placed. (See "Fire safety in the operating room", section on 'Special precautions during airway surgery'.)

Death — Intraoperative death in association with tracheostomy is rare and often related to significant underlying cardiopulmonary disease or rupture of the innominate artery [53].

FOLLOW-UP — Many experts, including us, do not routinely perform chest radiography. However, we obtain chest radiography if location of the new device is in doubt or if pneumothorax or pneumomediastinum is suspected. In a retrospective review of 60 patients undergoing tracheostomy with bronchoscopic guidance, a postprocedure chest radiograph was only useful in detecting complications following procedures deemed difficult by an experienced operator [54]. (See 'Pneumothorax/pneumomediastinum from a false tract' above.)

We do not routinely administer prophylactic antibiotics.

Postoperative care in the intensive care unit and maintenance tracheostomy care are discussed separately. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Weaning from mechanical ventilation" and "Society guideline links: Airway management in adults".)

SUMMARY AND RECOMMENDATIONS

Tube types – Commercially available tracheostomy tubes come in a variety of dimensions and styles and are made of polyvinyl chloride, silicone, or polyurethane; metal tracheostomy tubes are made of silver or stainless steel and are rarely used. (See 'Tube types' above.)

Tracheostomy tubes typically have an adapter that attaches to the ventilator, a flange that attaches to the neck, and a shaft which is curved or angled to accommodate the tracheostomy tract (picture 1 and picture 4 and picture 2). (See 'Components' above.)

Most tracheostomy tubes are nonfenestrated and have an inflatable cuff (picture 5). Tracheostomy tubes can be single-cannula or dual-cannula devices (picture 1) and come in many different dimensions (length and diameter (picture 3)). (See 'Single cannula, dual cannula' above and 'Dimensions and shape' above and 'Fenestrated/nonfenestrated, cuffed/uncuffed' above.)

Choosing open versus percutaneous – Tracheostomy can be performed as an open surgical procedure or percutaneously. Choosing between surgical or percutaneous tracheostomy depends upon institutional expertise and select conditions.

We favor surgical tracheostomy in patients with features listed in the table (table 1). (See 'Selecting percutaneous versus operative' above.)

Selecting a tracheostomy tube – When initially selecting a tracheostomy tube, no one size fits all, and the process is generally at the discretion of the operating surgeon or proceduralist. (See 'Selecting a tracheostomy tube' above.)

Factors that we take into consideration include patient age, weight, and height; neck and tracheal size; tracheal pathology (eg, tracheomalacia, distorted trachea); and the purpose(s) of tracheostomy (eg, airway secretion clearance, ventilation, weaning, phonation).

We typically select a commercially available, size 6 to 8, nonfenestrated, cuffed, single- or dual-cannula tracheostomy tube that is standard in length (approximately 60 to 65 mm (picture 5)). However, customized devices are available and can be used in special circumstances (eg, extra-long tracheostomy tubes may be needed in patients who are tall or have obesity or significant tracheomalacia (picture 6)).

Tracheostomy techniques – Elective, open surgical tracheostomy is most often performed under general anesthesia in the operating room (OR), while percutaneous tracheostomy can be performed at the bedside or in the OR. Tracheostomy is an aerosol-generating procedure such that appropriate personal protective equipment should be worn for high-risk transmissible organisms. (See 'Tracheostomy techniques' above.)

For surgical tracheostomy, a series of incisions and dissections are made until the trachea is exposed. Another incision is made between the second and third tracheal rings, through which a tracheostomy tube is inserted. (See 'Surgical (open)' above.)

In percutaneous tracheostomy, after a skin incision, pretracheal tissue is bluntly dissected to expose the trachea and under bronchoscopic guidance, the tracheostomy tube is placed using a Seldinger and a single progressive dilator technique. (See 'Percutaneous' above.)

Complications – Both techniques have a low risk of intraoperative complications when performed by an experienced operator. Intraoperative complications include bleeding, pneumothorax/pneumomediastinum (due to the creation of a false tract anterior to the trachea), esophageal perforation, tracheal ring fractures, and airway loss or fire. (See 'Intraoperative complications' above.)

Follow-up – We do not routinely perform chest radiography or administer antibiotic prophylaxis following tracheotomy placement unless they are indicated for another reason. (See 'Follow-up' above and "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Postoperative care'.)

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Topic 131519 Version 12.0

References

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