Percutaneous dilatational tracheotomy

Anesthetize the skin at the planned tracheotomy site with mepivacaine 1% and 1:100,000 epinephrine (about 5 ml).

The skin will become ischemic and turn white; this will lessen any bleeding.

Tracheal assessment Pull back the ventilation tube to the level of the vocal cords.

Transilluminate the site of the planned puncture from the lumen of the trachea with the light of the bronchoscope.

Puncture in a strictly median and slightly caudad direction.

Concurrent bronchoscopic monitoring helps prevent puncture of the posterior tracheal wall or the cuff of the endotracheal tube and verify the correct position of the puncturing needle.

When air is aspirated into the syringe, the needle is within the tracheal lumen.

Gain access through a horizontal skin incision of about 1.5 cm through which the tracheotomy tube will be introduced later.

Do not leave any skin bridges near the Seldinger guidewire.

Now gently screw down the plastic dilator over the guidewire until it stops and then remove it immediately.