Perioperative management - Percutaneous dilatational tracheotomy

• Prolonged mechanical ventilation (> 10 days)

Benefits compared with intubation:

• No injury of the arytenoid cartilages
• Prevention of mucosal lesions (nose/mouth, vocal cords, trachea)
• Less airway resistance (decreased ventilatory effort)
• Less dead space
• Better fixation
• Easier oral care
• Less analgesics/sedatives required
• Better patient comfort
• Easier weaning

• Emergencies
• Difficult airways suspected
• Rather difficult or even impossible standard intubation
• Infection at the planned puncture site
• Difficult anatomical conditions (e.g., large goiter, head reclination not possible)
• Unstable cervical spine
• Coagulation disorders
• Need for permanent tracheostomy or patient discharged home > epithelialized permanent tracheostomy required

• Coagulation panel
• Bronchoscopy

Fiberoptic monitoring while puncturing the trachea is strongly recommended.

• Bleeding
• Infection
• Tracheal injury
• Surgical revision
• Pneumothorax
• Injury to the recurrent nerve
• Cutaneous emphysema (incl. mediastinal emphysema)
• Scarring of the tracheostomy

The procedure is performed with the patient ventilated and under analgesia/sedation.

• Supine, with head reclined (as in thyroidectomy)
• Both arms adducted

Can be performed as bedside procedure on the ICU!

First assistant and scrub nurse face the surgeon, with the scrub nurse at knee-level of patient.

• Prepping set
• Percutaneous tracheotomy kit
• Bowl with saline
• Mepivacaine
• Epinephrine

In case of possible complications:

• Crash cart with medications and kit for standard intubation

• Bronchopulmonary hygiene. To keep the airways clear and prevent infections and atelectasis in patients on mechanical ventilation, the bronchial secretions must be suctioned.
• Dressing changes: The dressing around the tracheostomy should be changed at least once daily. To prevent wound infections, the dressings must always be changed under sterile conditions.
• Humidifying the inspired air: The tracheostomy bypasses the upper airways. Their functions must be replaced by artificial means. Primarily this includes warming and humidifying the inspired air.
• Cuff pressure monitoring: During mechanical ventilation, the cuff ensures that inspired gas cannot escape from the trachea or liquid enter it. To prevent any tracheal injuries, only tubes with low-pressure cuffs are used in prolonged mechanical ventilation. Cuff pressure can be monitored with dedicated pressure gauges and should be about 15-20 mmHg.

Tracheostomy cannula change: Leave the tracheostomy tube in place for the first 48 hours after surgery because a proper canal will not have formed yet. Later, cannula changes are once weekly in most cases.