Percutaneous Tracheotomy - A Detailed Review

1. Definition and Historical Background

• First described by Toye and Weinstein in 1969 using the Seldinger technique
• Popularized by Ciaglia in 1985 with his dilational percutaneous technique
• Now the most commonly performed alternative airway procedure in ICU patients on prolonged mechanical ventilation
• Cummings Otolaryngology Head and Neck Surgery
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery

2. Indications

3. Contraindications

Absolute

• Children / pediatric age group - the collapsible, mobile trachea is difficult to stabilize; bronchoscope management through a pediatric ETT is impractical
• Severe clinical instability - when bronchoscopy is not tolerated

Relative (favor open technique)

• Midline neck masses - obscure landmarks
• Uncorrectable coagulopathy (PT/PTT >1.5x control, platelets <50,000/mm³) - hemostasis cannot be achieved as in open surgery
• High respiratory support (FiO2 >70%, high PEEP) - deoxygenation risk during bronchoscopy
• Morbid obesity - BMI >30 kg/m² is an independent risk factor; landmark palpation difficult; 80% of accidental decannulations occur in this group
• Cervical spine instability - neck extension required
• High-riding innominate artery or aberrant vasculature
• Previous neck surgery / radiation - distorted anatomy
• Suspected cervical tracheal pathology (stenosis, tumor)

4. Equipment

• 14-gauge (or 22-gauge seeker) introducer needle with syringe
• J-tipped guidewire
• 12-Fr short dilating catheter (initial dilator)
• Single tapered hydrophilic-coated dilator (Blue Rhino - replaced older serial dilators)
• Appropriately sized tracheostomy tube loaded on loading dilator
• Flexible videobronchoscope
• 1% lidocaine with 1:100,000 epinephrine

5. Pre-Procedure Evaluation

1. History and respiratory status review - FiO2, PEEP, ventilator settings
2. Physical examination - palpate thyroid cartilage, cricoid, tracheal rings 1-3; inspect for midline vessels
3. Review existing CT imaging - assess vascular anatomy, particularly high-riding innominate artery or aberrant vessels
4. Ultrasound assessment - increasingly recommended to evaluate vasculature overlying the puncture path
5. Laboratory studies - platelet count, PT, PTT, BUN (uremia requires DDAVP pretreatment)
6. Staffing - anesthesiologist or airway-trained physician at head of bed to manage ETT, perform bronchoscopy, and administer sedation; scrub nurse as non-sterile circulator

6. Step-by-Step Technique (Ciaglia PDT - Standard Method)

Setup

1. Place shoulder roll to extend the neck (unless contraindicated)
2. Increase FiO2 to 1.0
3. Administer sedation, analgesia, and short-acting paralysis to minimize coughing
4. Prep and drape in sterile fashion
5. Identify landmarks: hyoid, thyroid cartilage, cricoid cartilage, tracheal rings

Incision and Dissection

1. Inject 1% lidocaine with 1:100,000 epinephrine (up to 10 cc) into skin and subcutaneous tissue
2. Make a 1-2 cm horizontal incision below the inferior border of the cricoid toward the sternal notch
3. Bluntly dissect with a hemostat in the midline through subcutaneous tissue until tracheal rings are palpable

Bronchoscopic Guidance

1. Advance bronchoscope through the ETT - position it at the distal end of the tube
2. Withdraw the ETT to the level of the vocal cords - the bronchoscopist uses transillumination through the anterior neck incision to gauge how far to retract
3. Deflate the ETT cuff

Needle Entry

1. Insert a 14-gauge (or 22-gauge seeker) needle on a saline-filled syringe between tracheal rings 1-2 or 2-3 (ideal entry zone is between 10 and 2 o'clock on the anterior tracheal wall)
2. Confirm placement by:
   • Aspiration of air (or air bubbling through saline)
   • Direct bronchoscopic visualization of needle entering the tracheal lumen midline, away from the posterior membrane

Seldinger Technique - Wire and Dilation

1. Remove syringe while holding needle steady; advance J-tipped guidewire toward the carina through the needle
2. Remove needle/catheter, leaving guidewire in place
3. Pass the short 12-Fr dilating catheter (guiding catheter) over the wire for initial dilation
4. Load the tracheostomy tube onto the single tapered Blue Rhino dilator; advance the entire assembly over the guidewire under continuous bronchoscopic visualization - the dilator passes through the stoma while stretching the tracheal wall

Tube Placement and Confirmation

1. Once in the tracheal lumen, remove the guidewire, guiding catheter, and loading dilator while holding the tracheostomy tube in place
2. Inflate the cuff of the tracheostomy tube
3. Confirm position by:
   • Bronchoscopy through the ETT (confirm tube is below cords in lumen)
   • Bronchoscopy through the tracheostomy tube itself
   • Return of tidal volumes from ventilator once circuit connected
4. Secure with suture through flanges and neck ties
5. Remove ETT once tracheostomy is confirmed functional

7. Alternative Percutaneous Techniques

8. Bronchoscopic Guidance

• Without guidance: overall complication rate ~16.8%
• With bronchoscopic guidance: complication rate ~8.3%

9. Complications

Intraoperative / Early Complications

Late Complications

10. PDT vs. Open (Surgical) Tracheostomy

11. Post-Procedure Care

• Post-procedure chest X-ray mandatory in all patients (pneumothorax)
• Confirm correct tube position clinically and radiographically
• Cuffed tube used initially to protect airway from secretions; can be changed to uncuffed after 3-4 days
• Cuff pressure monitoring - must stay below mucosal capillary occlusion pressure to prevent subglottic stenosis
• Tube secured with neck ties (tied with head in flexion) or flanges sutured to skin
• Stepwise decannulation: downsize tube, cap tube, tape stoma, instruct patient on occlusion during speech and coughing
• Tracheocutaneous fistula if persistent requires staggered three-layer local tissue repair

12. Special Considerations

• Obesity (BMI >30): independent risk factor; 15% complication rate vs. 8% in non-obese; 80% of accidental decannulations occur in this group - consider open Björk flap
• Uremia: PDT can be performed safely but pretreat with DDAVP
• COVID-19 / aerosol-generating procedures: tracheotomy is an aerosol-generating procedure (AGP); requires full PPE, negative pressure room, minimal staff, bronchoscopy protocol modifications
• Children: PDT is contraindicated - mobile, collapsible trachea; inadequate ventilation during bronchoscopy through pediatric ETT

• Cummings Otolaryngology Head and Neck Surgery (Chapters on Percutaneous Tracheotomy)
• Current Surgical Therapy, 14th Edition (Percutaneous Dilatational Tracheostomy)
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery
• Bailey and Love's Short Practice of Surgery, 28th Edition
• Fishman's Pulmonary Diseases and Disorders
• Dong X et al. (2026) - PDT with vs. without bronchoscopic guidance PMID: 41845239
• Wen D et al. (2025) - Ultrasound- vs. landmark-guided PDT meta-analysis PMID: 40281422