PERCUTANEOUS TRACHEOSTOMY

RGUHS ENT Long Essay - 50 Marks

1. INTRODUCTION AND HISTORICAL BACKGROUND

• 1955 - Shelden et al.: first percutaneous tracheostomy concept reported
• 1969 - Toye and Weinstein: first modern percutaneous technique
• 1985 - Pasquale Ciaglia: described elective percutaneous dilatational tracheostomy (PDT) using serial dilators over a J-wire - the landmark paper (Chest 1985;87:715-719)
• 1990 - Griggs: introduced guidewire dilating forceps (GWDF) technique
• 1997 - Fantoni: translaryngeal tracheostomy (TLT)
• 1999 - Ciaglia Blue Rhino: single-step conical dilator (now most widely used worldwide)
• 2002 - PercuTwist: single screw-type dilator technique

2. ANATOMY RELEVANT TO PERCUTANEOUS TRACHEOSTOMY

                    ANTERIOR NECK - SURGICAL ANATOMY
    ┌────────────────────────────────────────────────────────┐
    │  SKIN → Subcutaneous fat → Platysma                   │
    │  → Investing fascia → Strap muscles (sternohyoid/     │
    │    sternothyroid) → Pretracheal fascia → TRACHEA      │
    │                                                        │
    │  ← Thyroid gland (isthmus overlies rings 2-4)         │
    │  ← Cricothyroid arteries (above, avoid)               │
    │  ← Inferior thyroid arteries (lateral, avoid)         │
    │  ← Brachiocephalic artery (below, avoid)              │
    │  ← Cricoid cartilage (landmark - do NOT stab above)   │
    └────────────────────────────────────────────────────────┘
    
    TARGET ZONE: Between 1st-2nd or 2nd-3rd tracheal rings
    (cricotracheal membrane = NEVER - risk of subglottic stenosis)

• Hyoid bone
• Thyroid cartilage (Adam's apple)
• Cricoid cartilage (ring-shaped)
• Cricothyroid membrane (NOT the target - above)
• 1st-4th tracheal rings (target: rings 1-2 or 2-3)
• Sternal notch (inferior limit)

3. INDICATIONS

3A. Box: Indications for Tracheotomy (Cummings, Box 7.1)

Specific indications for PERCUTANEOUS route:

• ICU patient requiring mechanical ventilation > 7-10 days
• Bedside procedure preferred (avoids OR transfer risk)
• Elective setting with palpable, accessible anterior neck
• Patient intubated and ventilated with continuous monitoring

4. CONTRAINDICATIONS

Absolute Contraindications:

• Emergency airway situation (prefer surgical tracheostomy or cricothyrotomy)
• Uncontrolled coagulopathy
• Non-palpable trachea (markedly obese neck, massive goitre)
• Age < 12-15 years (relative to absolute in children - anatomy too small)

Relative Contraindications:

• Morbid obesity (BMI > 40) - limited landmark palpation
• Short, fat neck
• Previous neck surgery/radiation
• Enlarged thyroid gland (goitre)
• High cervical lesion/instability (cannot extend neck)
• Severe coagulopathy (INR > 1.5, platelets < 50,000)
• Severe hypoxia requiring high FiO2 (brief apnea during procedure risky)
• Tracheal pathology (stenosis, malacia)
• Paediatric age group

5. EQUIPMENT REQUIRED

Percutaneous Tracheostomy Kit (Ciaglia Blue Rhino - most commonly used):

Figure: Percutaneous tracheostomy set (Scott-Brown's Otorhinolaryngology, Vol. 2, p. 1086)

1. Introducer needle (18-gauge, with plastic cannula)
2. Saline-filled syringe (10 mL)
3. J-tipped guidewire (Seldinger wire)
4. 12-Fr guiding catheter (loading dilator)
5. Hydrophilic-coated single conical dilator (Blue Rhino)
6. Tracheostomy tube (cuffed, size 7 or 8 for adults)
7. Sutures (0 prolene or silk for securing)

• Flexible fibroscope/bronchoscope (strongly recommended)
• Suction equipment, resuscitation trolley
• Monitoring: SpO2, ECG, BP, capnography
• Local anaesthetic: 1% lignocaine with 1:100,000 adrenaline

6. PRE-OPERATIVE ASSESSMENT AND PREPARATION

• Confirm indication and obtain consent
• Assess neck anatomy: palpate landmarks
• Check coagulation: INR < 1.5, platelets > 50,000
• Review imaging: CT/USS neck if anatomy unclear
• Ensure patient is adequately ventilated (consider increasing FiO2 to 100% pre-procedure)
• Check current endotracheal tube position (ETT must be present for airway security)
• Anaesthetic team and/or intensivist presence mandatory

• Supine with shoulder roll/sandbag beneath shoulders
• Neck extended (unless cervical spine injury contraindicated)
• Head in neutral position on a ring
• Patient placed square on table (shoulders level)

7. OPERATIVE TECHNIQUE - CIAGLIA BLUE RHINO (Step-by-Step)

FLOWCHART: Percutaneous Tracheostomy - Ciaglia Blue Rhino Method

╔══════════════════════════════════════════════════════════╗
║           PERCUTANEOUS TRACHEOSTOMY - FLOWCHART          ║
╠══════════════════════════════════════════════════════════╣
║  STEP 1: PATIENT PREPARATION                             ║
║  • Supine, shoulder roll, neck extended                  ║
║  • FiO2 100%, SpO2/ECG/NIBP monitoring                  ║
║  • IV sedation + analgesia (propofol + fentanyl)         ║
║  • Flexible bronchoscope inserted via ETT                ║
║  • ETT withdrawn to level of vocal cords (under scope)   ║
╠══════════════════════════════════════════════════════════╣
║  STEP 2: SITE PREPARATION                                ║
║  • Palpate thyroid, cricoid, tracheal rings              ║
║  • Mark puncture site: below 1st ring or 2nd-3rd ring   ║
║  • Infiltrate 1% lignocaine + adrenaline subcutaneously  ║
║  • Prep and drape the surgical field                     ║
╠══════════════════════════════════════════════════════════╣
║  STEP 3: SKIN INCISION                                   ║
║  • Horizontal 1.5-2 cm incision at planned site         ║
║  • Blunt dissection with artery forceps in midline       ║
║  • Through subcutaneous tissue to pretracheal fascia     ║
╠══════════════════════════════════════════════════════════╣
║  STEP 4: TRACHEAL PUNCTURE (Seldinger Technique)        ║
║  • 18G needle + cannula on saline-filled syringe         ║
║  • Pass at 90° to tracheal wall (slight caudal angle)    ║
║  • CONFIRM by:                                           ║
║    - Aspiration of air through saline (bubbles) AND      ║
║    - Bronchoscopic visualisation (see needle tip)        ║
║  • Needle should be at 10-2 o'clock on anterior wall    ║
║  • Withdraw needle, leave cannula in place               ║
╠══════════════════════════════════════════════════════════╣
║  STEP 5: GUIDEWIRE INSERTION                             ║
║  • Pass J-tipped guidewire through cannula into trachea  ║
║  • Wire directed inferiorly (into bronchial tree)        ║
║  • Confirm position bronchoscopically                    ║
║  • Remove cannula, keep wire in situ                     ║
╠══════════════════════════════════════════════════════════╣
║  STEP 6: INITIAL DILATION                                ║
║  • Pass 12-Fr guiding catheter (loading dilator) over    ║
║    guidewire into trachea                                ║
║  • This stiffens the wire and prevents kinking           ║
╠══════════════════════════════════════════════════════════╣
║  STEP 7: BLUE RHINO DILATION (Single Conical Dilator)   ║
║  • Load tracheostomy tube on conical Blue Rhino dilator  ║
║  • Hydrate dilator with saline (reduces friction)        ║
║  • Advance dilator + tube together over guiding catheter ║
║  • Rotate with GENTLE pressure - do NOT force            ║
║  • Bronchoscope confirms passage through anterior wall   ║
╠══════════════════════════════════════════════════════════╣
║  STEP 8: TRACHEOSTOMY TUBE INSERTION                     ║
║  • Advance tracheostomy tube into trachea                ║
║  • Remove dilator, guiding catheter, and guidewire       ║
║  • Inflate tracheostomy cuff with 5-10 mL air            ║
║  • Attach ventilator circuit                             ║
╠══════════════════════════════════════════════════════════╣
║  STEP 9: CONFIRMATION AND SECURING                       ║
║  • Confirm position: CO2 on capnograph, bilateral breath ║
║    sounds, bronchoscope through tracheostomy tube        ║
║  • Secure tube with sutures (0-prolene) to skin          ║
║  • Apply tracheostomy collar/ties                        ║
║  • CXR post-procedure                                    ║
║  • Dressing applied (split gauze under flange)           ║
╚══════════════════════════════════════════════════════════╝

8. TECHNIQUES / TYPES OF PERCUTANEOUS TRACHEOSTOMY

Comparison Table of All Techniques:

• Single step dilation vs. multiple dilators
• Hydrophilic coating reduces friction and mucosal trauma
• Lower complication rate in meta-analyses
• Faster procedure time
• Can be combined with bronchoscopic guidance

9. TRACHEOSTOMY TUBES

Types:

10. COMPLICATIONS

FLOWCHART: Complications of Percutaneous Tracheostomy

┌─────────────────────────────────────────────────────────────┐
│            COMPLICATIONS OF PERCUTANEOUS TRACHEOSTOMY       │
│                    (Classified by Timing)                    │
├─────────────────────────────────────────────────────────────┤
│                                                             │
│  IMMEDIATE (Intraoperative)                                 │
│  ├── Haemorrhage (minor: venous ooze; major: arterial)      │
│  ├── Desaturation / Hypoxaemia                              │
│  ├── Loss of airway (tube displacement/accidental extubation│
│  ├── Posterior tracheal wall perforation                    │
│  ├── Oesophageal placement (false passage)                  │
│  ├── Subcutaneous emphysema / Pneumothorax                  │
│  ├── Air embolism                                           │
│  ├── Paratracheal insertion                                 │
│  └── Death                                                  │
│                                                             │
│  EARLY (Within days to 1 week)                              │
│  ├── Tube obstruction (secretions, blood clot)              │
│  ├── Tube displacement / accidental decannulation           │
│  ├── Stomal infection / cellulitis                          │
│  ├── Surgical emphysema                                     │
│  ├── Aspiration                                             │
│  └── Ventilator-associated pneumonia (VAP)                  │
│                                                             │
│  LATE (Weeks to months)                                     │
│  ├── Tracheal stenosis (most important long-term)           │
│  ├── Tracheoarterial fistula (life-threatening)             │
│  ├── Tracheo-oesophageal fistula (TOF)                     │
│  ├── Persistent stoma / difficult wound closure            │
│  ├── Tracheomalacia                                         │
│  └── Dysphagia / dysphonia / impaired cough                │
└─────────────────────────────────────────────────────────────┘

Important Complications in Detail:

• Incidence: 1-2% (PDT) vs. 2-3% (surgical)
• Mechanism: mucosal injury at cuff site → fibrous scarring → subglottic/tracheal narrowing
• Prevention: keep cuff pressure < 20-25 cmH2O, proper tube size, avoid high stoma
• Presentation: progressive dyspnoea after decannulation

• Occurs within 3 weeks - rare (0.1%)
• Innominate artery eroded by low-lying tube or cuff
• Presents as sentinel bleed or massive haemoptysis
• Emergency treatment: hyperinflate cuff + urgent surgical ligation

• Immediate: anterior jugular veins, thyroid vessels
• PDT: lower risk than surgical tracheostomy (meta-analyses confirm)
• Table from Cummings: PDT vs. surgical tracheostomy complication comparison

11. ADVANTAGES OF PDT OVER SURGICAL TRACHEOSTOMY

12. ROLE OF BRONCHOSCOPY IN PDT

1. Real-time confirmation of needle tip position in trachea
2. Ensures midline placement (10 o'clock to 2 o'clock position)
3. Prevents posterior wall injury
4. Confirms correct inter-ring placement (below ring 1)
5. Confirms final tracheostomy tube position in trachea

• Identifies vascular structures overlying trachea
• Confirms midline and inter-ring position
• Reduces haemorrhagic complications

13. POST-OPERATIVE CARE

Immediate:

• CXR to exclude pneumothorax / confirm tube position
• Continue monitoring: SpO2, capnography
• Ensure secure fixation (sutures + collar ties)
• Avoid early tube change - PDT tubes should NOT be changed before day 10 (tract not yet established; risk of false passage)

Daily care:

• Inner cannula cleaning every 4-8 hours
• Stomal care: clean with NS, apply split gauze
• Suction via inner cannula
• Cuff pressure monitoring: maintain 20-25 cmH2O (use manometer)
• Humidification for all ventilated patients

Communication and swallowing:

• Speech-language pathology (SLP) assessment
• Speaking valve (Passy-Muir) - only with cuff deflated
• Blue dye swallow test to assess aspiration

14. DECANNULATION

Criteria for Decannulation:

• Underlying indication resolved
• Able to maintain patent airway without tube
• Adequate cough and secretion clearance
• Safe swallowing mechanism confirmed
• No significant residual tracheal pathology

Decannulation Protocol:

  ASSESS candidacy
       ↓
  DOWNSIZE tube (sequential)
       ↓
  CAPPING TRIAL (plug the tube for 24-48 hours)
       ↓
  If passes (SpO2 stable, no distress)
       ↓
  DECANNULATE
       ↓
  Apply occlusive dressing
       ↓
  Stoma closes spontaneously (3-10 days)

15. PERCUTANEOUS TRACHEOSTOMY IN SPECIAL SITUATIONS

1. Obese Patients:

• US guidance for site identification strongly recommended
• Longer-shank tracheostomy tubes needed
• Higher complication rate - some argue surgical preferred

2. COVID-19 Patients (Recent evidence):

• During pandemic: PDT widely used (ICU patients, high demand)
• Delayed tracheostomy (>10 days from intubation) adopted due to aerosol risk
• Arnold et al., J Bronchology Interv Pulmonol 2023 reported outcomes of PDT in SARS-CoV-2 respiratory failure patients
• Modified PPE protocols developed for aerosol-generating procedure

3. Anticoagulated Patients:

• Bridging therapy protocols
• Fresh frozen plasma / vitamin K to correct INR < 1.5 before procedure

4. Paediatric Patients:

• PDT generally AVOIDED in children < 12 years (Namavarian et al., systematic review, Int J Pediatr Otorhinolaryngol 2024)
• Smaller tracheal diameter, softer cartilage, higher complication risk
• Surgical tracheostomy preferred in children

16. COMPARISON: PDT vs. SURGICAL TRACHEOSTOMY (Meta-Analysis Summary)

17. RECENT ADVANCES (2020-2025)

1. Ultrasound-guided PDT: Pre-procedural and real-time ultrasound guidance reduces vascular injury, confirms correct inter-ring placement, and identifies aberrant vessels. Now considered complementary to bronchoscopy.
2. Single-dilator technique dominance: Meta-analysis confirms Ciaglia Blue Rhino (single conical dilator) has fewer failures and complications than multi-dilator or forceps techniques.
3. COVID-19 experience: Pandemic validated PDT as a safe bedside procedure even in high-risk ventilated patients; timing protocols and PPE adaptations now standardised.
4. Tracheostomy weaning protocols: Personalised, multidisciplinary weaning teams shown to reduce ICU stay and improve decannulation rates.
5. Videolaryngoscope guidance: Some centres now use video-laryngoscopic or transnasal flexible scope to guide PDT instead of bronchoscopy, with comparable safety.
6. Robotic/AI-assisted tracheostomy: Experimental - robotic platforms for surgical tracheostomy being evaluated; not yet clinical standard.
7. Early vs. late timing: Lais & Piquilloud (2025) confirm personalised approach - no universal timing rule; early tracheostomy (< 7 days) beneficial in select populations (neuro-ICU, prolonged weaning expected).
8. PDT in paediatrics: Systematic review (2024) confirms PDT feasible in select adolescents but surgical tracheostomy remains gold standard in children.

18. SUMMARY DIAGRAM: PDT AT A GLANCE

┌──────────────────────────────────────────────────────────┐
│           PERCUTANEOUS TRACHEOSTOMY - SUMMARY            │
├──────────────┬───────────────────────────────────────────┤
│ INDICATIONS  │ Prolonged MV > 7-10 days, airway          │
│              │ obstruction, pulmonary toilet              │
├──────────────┼───────────────────────────────────────────┤
│CONTRAINDICS  │ Emergency, paediatrics, uncorrected        │
│              │ coagulopathy, non-palpable trachea         │
├──────────────┼───────────────────────────────────────────┤
│ GOLD         │ Ciaglia Blue Rhino (single conical         │
│ STANDARD     │ dilator) + Bronchoscopic guidance          │
├──────────────┼───────────────────────────────────────────┤
│ KEY STEPS    │ Position → Puncture (ring 1-2/2-3)        │
│              │ → Guidewire → Catheter → Dilate → Tube    │
├──────────────┼───────────────────────────────────────────┤
│ COMPLICATNS  │ Haemorrhage, tracheal stenosis,            │
│              │ tracheoarterial fistula, displacement      │
├──────────────┼───────────────────────────────────────────┤
│ ADVANTAGE    │ Bedside, lower infection, smaller scar,    │
│              │ faster, less costly                        │
├──────────────┼───────────────────────────────────────────┤
│ TUBE CHANGE  │ NOT before Day 10 (PDT)                    │
├──────────────┼───────────────────────────────────────────┤
│ RECENT ADV   │ US guidance, COVID protocols, personalised │
│              │ timing, single-dilator meta-analysis data  │
└──────────────┴───────────────────────────────────────────┘

REFERENCES

1. Scott-Brown's Otorhinolaryngology Head & Neck Surgery (8th ed.) - Chapter 72, Vol. 2, pp. 1085-1087
2. Cummings Otolaryngology Head and Neck Surgery (7th ed.) - Chapter 7, Box 7.1, Box 7.3, pp. 134-145
3. Bailey and Love's Short Practice of Surgery (28th ed.) - Percutaneous Tracheostomy section
4. Ciaglia P et al. - Elective percutaneous dilatational tracheostomy. Chest 1985;87:715-719
5. Delaney A, Bagshaw SM, Nalos M - PDT vs surgical tracheostomy, systematic review and meta-analysis. Crit Care 2006;10:R55
6. Khaja M, Haider A, et al. - Percutaneous Tracheostomy: A Bedside Procedure. Cureus 2022. PMID: 35573523
7. Lais G, Piquilloud L - Tracheostomy: update on why, when and how. Curr Opin Crit Care 2025. PMID: 39588741
8. Namavarian A et al. - Percutaneous tracheostomy in the pediatric population: systematic review. Int J Pediatr Otorhinolaryngol 2024. PMID: 38185003
9. Moore et al. - An updated review in percutaneous tracheostomy. AME Medical Journal
10. Dhingra PL - Diseases of Ear, Nose and Throat (6th ed.) - Tracheostomy chapter
11. Hazarika P - Textbook of Ear, Nose and Throat - Tracheostomy

RGUHS Exam Tip: This is a 50-mark long essay, so cover all sections above. The examiner expects: (a) definition + historical note, (b) anatomy, (c) indications/contraindications in tabular/box format, (d) step-by-step technique with a flowchart, (e) types of PDT, (f) complications (classified as immediate/early/late), (g) post-operative care, (h) comparison with surgical tracheostomy, and (i) recent advances. Drawing a neat flowchart of the procedure and the complications classification diagram will fetch full marks. Citing Cummings (Box 7.3) and Scott-Brown's (Fig. 72.6) demonstrates textbook familiarity expected at the RGUHS MS ENT level.