Percutaneous Tracheostomy - Definition, Technique, and Contraindications

Introduction

Inhaling oxygen and exhaling carbon dioxide make the breathing system of the human body. It carries utmost importance in the life of human beings because breathing oxygen reaches the cells of every part of the body that keeps them alive and functional.

When the breathing system is interrupted or obstructed, an alternative must be provided to maintain adequate breathing. Tracheostomy is one such surgical procedure that helps the patient breathe by inserting a tube from the trachea present in the neck. Percutaneous tracheostomy is a less invasive method to insert the tube and has become a common practice.

What Is Tracheostomy?

It is a surgical procedure through which a tube (tracheostomy tube) is inserted through an opening in front of the neck into the windpipe or trachea. It is done to help the patient breathe.

What Is Percutaneous Tracheostomy?

It is a minimally invasive procedure where the tracheostomy tube is inserted into the trachea without visualization.

What Is the Other Common Name for Percutaneous Tracheostomy?

It is also called percutaneous dilatational tracheostomy (PDT).

What Is the Difference Between Open and Percutaneous Tracheostomy?

When to Do Percutaneous Tracheostomy?

Percutaneous tracheostomy is indicated for patients who have:

• Acute respiratory failure.

• Upper airway obstruction, such as vocal cord paralysis.

• Neurologic disease - for airway protection.

• Brain injury - for airway protection.

• Airway secretions - need pulmonary hygiene.

• Prolonged ventilator indications, more than seven days.

• To reduce sedation requirements.

What Is the Anatomy of the Trachea?

The human neck has hyoid bone - which provides stability to the airway, present below the chin in the center. Below the hyoid bone, thyroid cartilage is present, after which cricothyroid membrane and cartilage are present. The tracheal rings can be felt through palpation and are present below the cricoid cartilage. The length of the trachea varies and depends on the bodybuilding, the curvature of the spine, the diameter of the chest, etc., which is located 2 to 2.5 cm deep into the skin. The tracheostomy is done in the tracheal rings - the second and third rings. The esophagus or food pipe is present behind the trachea. It is important to prevent injury to the esophagus while doing a tracheostomy.

How to Perform a Percutaneous Tracheostomy?

There are a few techniques to perform percutaneous tracheostomy:

1. Ciaglia Serial Dilatation Technique: This was the first technique performed bedside with the help of dilatators instead of guidewires. Initially, the site of insertion of the tracheostomy tube was cricoid cartilage. This technique has been modified with time and is no longer used.

2. Ciaglia Single Dilator Technique: It is known as Ciaglia blue rhino. It is simpler than the previous technique and uses a single-beveled, curved, or tapered hydrophilic dilator. It is the most commonly used technique.

3. Grigg’s Percutaneous Technique: It is known as the guidewire dilator forceps technique. Special forceps are used instead of a guidewire to perform the dilatation of tissues in a single step. The pretracheal and tracheal space is dilated through forceps. This technique is not performed nowadays because it results in more serious damage to soft tissue.

4. Fantoni Translaryngeal Tracheostomy: A needle puncture is done in the trachea, after which guidewire is passed through the vocal cords located in the backward direction from the trachea. The tracheostomy tube and dilator are inserted into the larynx and come out through the front tracheal wall. The tracheostomy tube is separated from the dilator and is rotated at 180 degrees angle. It is a complicated procedure.

5. Fantoni Translaryngeal Tracheostomy: A single-step dilator is used, which is of screw type. The dilator is rotated in a clockwise direction. This technique has reported more cases of tracheal ring fractures and damage to tracheal walls.

6. Balloon Dilatational Tracheostomy: It is a single-step technique in which a modified angioplasty balloon is inflated instead of the guidewire to perform the dilation of the trachea. The balloon is deflated, and the tracheostomy tube is inserted.

Technique for Insertion:

• The procedure is performed in an operating theater with the help of a surgeon, anesthetist, and other helpers.

• Capnography is done, which is now mandatory to assess the ventilation, ensure correct placement of the tracheostomy tube, etc., monitoring the partial pressure of carbon dioxide in the respiratory gasses of the patient.

• The neck skin is prepared with Chlorhexidine or iodine solution.

• Local anesthesia is given in the neck region of the patient.

• The anatomical landmarks of the neck, such as cricoid cartilage and the sternal notch, are identified.

• A 2 cm long incision is made in a horizontal plane between the cricoid cartilage and sternal notch.

• Blunt dissection of the tracheal tissues is done to palpate the trachea.

• A needle or cannula is inserted into the trachea at the second and third cartilage ring level to aspirate the air.

• This is done with a bronchoscope - a thin tube through which the trachea can be seen directly to ensure the correct placement of the needle and tube and identify the entry point. This process is called bronchoscopy.

• The needle or cannula is withdrawn, and a tracheostomy tube and a dilator are inserted by following the technique mentioned above.

What Is Ultrasound Percutaneous Tracheostomy?

Before inserting the tracheostomy tube, an ultrasound of the neck region is performed to estimate the distance of the trachea from the skin. This is done preoperatively nowadays. It helps to identify the blood vessels and enlarged thyroid isthmus and avoid complications.

What Are the Contraindications of Percutaneous Tracheostomy?

Percutaneous tracheostomy cannot be performed in the following:

• Infants.

• Presence of infection at the surgery site.

• Cervical spine injury.

• Enlarged thyroid glands.

• Complex and difficult anatomy such as the short neck, obesity, etc.

What Are the Complications of Percutaneous Tracheostomy?

The possible complications are listed below:

• Bleeding at the surgery site.

• Loss of airway.

• Hypoxia (low oxygen levels in the blood).

• Pneumothorax (collapsed lung because of air leakage between the lungs and chest wall).

• False tract or passage of the trachea that causes displacement of the tracheostomy tube. Sometimes, the tracheostomy tube is inserted into the false tract.

• Pneumomediastinum (a condition that causes injury or pneumothorax where the air leaks into the space between the lungs and chest wall).

• Injury to surrounding body parts such as the esophagus.

• Fracture of tracheal rings.

• Obstruction on the tracheal tube.

• Displacement of the tracheal tube.

• Delayed healing.

• Infection after surgery.

• Scarring of the neck.

• Difficulty in swallowing.

• Voice changes.

Conclusion

Percutaneous tracheostomy is a commonly practiced technique for critical patients or who are seriously ill. It comes with a few complications and risks, but by following appropriate techniques and proper patient selection, the complications can be avoided. Because there are various techniques available, there is no perfect or gold standard technique to follow, but percutaneous tracheostomy is preferred over surgical or open tracheostomy. Based on important factors such as the need for the procedure, the condition of the patient, etc., the selection of the technique must be made that will be best suitable.