Percutaneous Dilatational Tracheostomy

W15 Percutaneous Dilatational Tracheostomy



Cherisse Berry, Daniel R. Margulies



image Before Procedure



Indications



• Requirement of a temporary or long-term artificial airway for prolonged mechanical ventilation

• Management of secretions

• Nonemergency airway obstruction


Contraindications



• Relative contraindications:
• Inability to clearly palpate and identify tracheal landmarks

• Enlarged thyroid or other neck mass

• Active infection at the site

• Emergency need for airway

• Positive end-expiratory pressure (PEEP) greater than 20 cm H2O

• Previous tracheostomy

• Previous surgical scar

• Bleeding

• Increased intracranial pressure

• Clinically significant coagulopathy

• Documented tracheomalacia

• Cervical irradiation

• Morbid obesity

• Maxillofacial or neck trauma

• Lack of cervical spine clearance

• Inability to extend the neck because of cervical spine fracture

• In addition, we do not perform the procedure in patients younger than 16 years of age because of the scarcity of experience reported in pediatric patients.


Equipment


Equipment required at the bedside to perform the percutaneous dilatational tracheostomy (PDT) procedure should include:


• PDT introducer set (Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer Set #C-PTIS-100-HC, Cook Critical Care, Bloomington, Indiana)

• Bronchoscope with video monitor display and bronchoscopy endotracheal tube adapter

• Continuous electrocardiographic (ECG) monitor

• Blood pressure monitoring device

• Pulse oximeter

• Free-flowing intravenous catheter

• Mechanical ventilator

• Suction

• Resuscitation (“crash”) cart

• Open tracheostomy instrument tray (unopened)

Supplies required at the bedside include:


• Chloroprep or other solution for skin preparation

• 4 × 4-inch bandages

• Syringes and needles

• Sterile gowns and gloves

• Shiley Percutaneous Dual Cannula Cuffed Tracheostomy tube

• Kelly clamp

• Sterile saline solution

Medications required at the bedside include:


• 1% Xylocaine with epinephrine 1 : 100,000

• Midazolam, 1 mg/mL injectable or other appropriate sedative

• Morphine, 10 mg injectable or other appropriate narcotic

• Vecuronium, injectable or other appropriate paralyzing agent

• Sterile normal saline flush solution

• Other medications at the discretion of the PDT operator

• The choice of a PDT introducer set may vary by institution; ours includes the set listed only because we have significant experience with it. However, it is critical that only one type of PDT introducer set be in use in an institution at any given time. To ensure maximum safety, every aspect of this procedure must be standardized, especially the equipment used.


image Anatomy


The thyroid notch and cartilage are palpated, followed by the cricothyroid membrane and cartilage and the tracheal rings. It is essential that the tracheal puncture be made inferior to the cricoid cartilage landmark. If the second and third tracheal rings cannot be distinctly identified, the procedure is aborted, and an open tracheostomy is performed.



image Procedure



• A single tapered PDT dilator and kit with simultaneous intraoperative bronchoscopy is used.

• Two teams are used simultaneously. One team manages the endotracheal tube, and the other manages the placement of the tracheostomy tube.

• The patient’s physiologic parameters, including arterial oxygen saturation, are monitored continuously throughout the procedure by the intensive care unit (ICU) nurses and respiratory therapist.

• Intravenous sedation and paralytic agents are administered as required, and the patient is fully ventilated via an endotracheal tube.

• The patient is positioned with the neck slightly extended and a pillow under the shoulders.

• Under sterile conditions, the PDT dilators and tracheostomy tube must be prepared.
• The Blue Rhino tracheal dilator is water activated, so it is dipped in sterile saline or water to enhance its lubricant coating.

• The Shiley Percutaneous Dual Cannula Cuffed Tracheostomy Tube is designed specifically to be used with the Cook Percutaneous Tracheostomy Introducer Set. Depending on the size of the patient, it is prepared by inflating the balloon to ensure integrity and then collapsing the balloon by withdrawing all air.

• The tracheostomy tube, with the cuff completely deflated, is inserted over the introducer dilator as one unit, placed 2 cm from the tip of the dilator and then lubricated with sterile gel. The Shiley’s tapered distal tip and inverted cuff shoulder are specifically designed for easier insertion. It is important that the tracheostomy tube be placed exactly 2 cm from the tip. If it is placed more than 2 cm from the tip, it will likely not enter the trachea. If it is advanced too far and placed less than 2 cm from the tip, the trachea may be damaged upon insertion.
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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Percutaneous Dilatational Tracheostomy

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