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Percutaneous Tracheostomy | NEJM


Before starting the process, the team must take time to verify the patient’s identity and the procedure to be performed. After the time-out, the patient’s nurse should administer a short-acting paralytic agent and, if necessary, additional sedation. Inadequate paralysis increases the risk of inadvertently occurring when the oral endotracheal tube is being manipulated. After administering the agent, the nurse should move out of the room to minimize the risk, but should be available immediately and remodel the room if assistance is needed.

Sterilizing and wrapping the anterior neck, ensuring that draping will allow easy access to the oral endotracheal tube. Make a 2 to 3 cm vertical incision in the neck that protrudes the trachea directly and lies below the cryoid cartilage. Blunt the pretracheal tissue with the dissection device until the trachea becomes unstable. In patients who require medical anticoagulants or who have any risk of bleeding, it may be advisable to place a purse-string suture around the tracheostomy incision. The purse-string suture is placed but not tied during this phase. After the tracheostomy tube is inserted it will be tied to provide additional hemostatic control. The suture is usually removed on the second postoperative day with no evidence of bleeding. The tracheostomy tube should not be placed on its own. Removal of a tracheostomy tube results in ulcers in the skin and does not inadvertently prevent dissolution.

Ask the respiratory therapist to induce apnea by placing the ventilator on standby. Disconnect the oral endotracheal tube from the ventilator circuit and attach the bronchoscope adapter to the tube. Insert the bronchoscope into the adapter, reconnect the circuit, and resume ventilation. Push the bronchoscope forward into the airway. Briefly survey the trachea and cleanse any obstructive secretions.

Once all team members are ready to proceed, advance the bronchoscope into the oral endotracheal tube until the camera aligns with the end of the tube. At that point, the respiratory therapist should again induce apnea and then deflect the tube cuff. Respiratory therapists and bronchoscopists then slowly withdraw the tube and bronchoscope together until the subglottic site is visible. Tilt of the anterior trachea by the surgeon may facilitate identification of these sites. Some physicians use transillumination (ie, visualization of bronchoscopic light through the skin) to facilitate tube positioning.

The bronchoscope is kept within the oral endotracheal tube at all times to ensure airway control. Accurate communication and coordinated movement between respiratory communication and bronchoscopists are important for the prevention of accidental deletion.

Once the oral endotracheal tube has been retracted to an appropriate location, perform a tranchostomy, using the Seldinger technique. Insert the introducer needle directly through the anterior wall of the trachea under bronchoscopic visualization. The needle should be inserted at the level of the second tracheal ring, perpendicular to the trachea, with a bevel at the bottom. The placement of the needle bevel in this downward position will help direct the guidance to the distal trachea. This is important to avoid damaging the balloon on the oral endotracheal tube. In the event that the patient’s condition becomes clinically unstable or has difficulty performing a tracheostomy, as long as the balloon remains intact, the oral endotracheal tube just advanced to its original location and normal ventilation resumed. goes. Additional supplies or personnel may be assembled. If the balloon is compromised, it also has the ability to provide positive pressure ventilation. A new airway should be rapidly established via oral endotracheal intubation with a tracheostomy or an intact tube.

Insertion of Introducer Needles and Guidelines.

The introducer needle and guideware are inserted directly through bronchoscopic guidance (inset) through the straight wall of the trachea.

Expansion of trachea.

The shorter tracheal dilator is advanced on the guideline for thinning the path. The small tracheal dilator is removed, the protective sheath is loaded (panel A), and advanced on the single-stage progressive dilator guidewire (panel B).

Feed the guideware through the needle and visualize it moving farther towards the carina. Move the wire slightly beyond the carina (Line number 2). Remove the needle above the wire, keeping the wire within the trachea at all times. Advance the small tracheal dilator above the wire to thin the tract. Remove the small tracheal dilator and, with the protective sheath loaded, move the single-stage progressive dilator over the wire (Picture 3). Remove the progressive dilator, keeping the wire and protective sheath in place. (The traces of the edge of the progressive deleter guide the depth at which it is inserted.) Next, insert the tracheostomy tube directly into the trachea above the wire and protective sheath. If a flexible tracheostomy tube is used, insert the tube with a curve directed toward the patient’s head. Once the tube is visualized in the patient’s trachea, rotate the tube at 180 degrees. This will position the tube in its normal orientation and prevent it from forming a pretracal plane. Alternatively, a nonflexible tracheostomy tube can be loaded onto an insertion tracker and advanced onto the wire and the protective sheath in the trachea.

Once the tube is in place, remove the protective sheath, wire, and trocar (if used), inflate the tracheostomy cuff, connect the circuit to the tracheostomy tube, and resume ventilation. The presence of end-tidal carbon dioxide confirms placement in the airways. Alternatively, the bronchoscope can be retrofitted to confirm vision within the airway via a tracheostomy tube. The position of the tracheostomy should be confirmed with flexion and extension of the patient’s head. Only after this the oral endotracheal tube should be removed.

Once satisfactory placement is confirmed, secure the tracheostomy tube with a tracheostomy collar. If a purse-string suture was placed, tie the suture down to close the skin incision around the tracheostomy. Once the patient is ventilated through a safe tracheostomy tube, the oral endotracheal tube can be removed.



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