Tracheostomy Insertion Techniques
OVERVIEW
Approach to percutaneous dilatational tracheostomy (PDT) procedure:
- assess for appropriateness of PDT
- consent
- fast
- IV access
- preoxygenate
- emergency re-intubation gear
- standard monitoring (including ETCO2)
- personnel: surgeon, anaesthesia + bronchoscopist (all with adequate experience or supervision)
- GA + LA
- pull ETT back to cords (?LMA use)
- sterile technique
- insert tracheostomy
DIFFERENT TECHNIQUES
- Surgical (not described here)
- Ciaglia technique (graduated dilatation)
- Griggs (Portex) technique
- Translaryngeal approach
CIAGLIA TECHNIQUE (GRADUATED DILATATION)
Method
- horizontal incision through skin (1.5cm) – traditional Ciaglia Technique was a vertical incision
- blunt dissection down to tracheal rings
- needle puncture through first and second tracheal ring
- once air aspirated insert cannula into trachea -> guidewire
- graduated dilation
- tracheostomy insertion
Pros
- widely used
- well established
- low complication rate
- gradual dilation
- can insert any size trachy
Cons
- requires experienced operators
- loss of PEEP
- damage to vocal cords with ETT position
- takes minutes to dilate
- spray of blood with inspiration
- damage to posterior wall of trachea (can minimise with bronchoscope)
GRIGGS (PORTEX) TECHNIQUE
Method
- once guidewire inserted use of guidewire dilating forceps
Pros
- less steps
- faster dilation
- can insert any size trachy
Cons
- requires experienced operators
- sterilization of forceps
- loss of PEEP
- damage of vocal cords with ETT position
- more abrupt dilation -> more damage
- spray of blood with inspiration
- damage to posterior wall of trachea (minimise with bronchoscope)
- may want to insert different trachy – wastage
TRNASLARYNGEAL APPROACH
Method
- ETT tube is pulled back to gain access to the trachea
- curved cannula introduced into the lumen between the second and third tracheal rings
- guidewire introduced and advanced in retrograde direction
- when wire in the pharynx it is grabbed using a Magills forceps
- patient then intubated with thin ETT
- tracheal cannula then attached to wire and passed distal to larynx
- tracheal cannula then pulled through anterior tracheal wall and cut at a predetermined length and rotated 180 degrees by means of an obturator
- thin ETT removed and tracheostomy cuff inflated
Pros
- low complication rate
- safely used in coagulopathy
- initial tracheal puncture under vision from inside trachea
- avoids damage to posterior tracheal wall
- allows V throughout procedure
- can be done as one person technique
Cons
- less widely known outside Europ
- more fiddly
- needs experienced operator
- requires lightsource and scope
- V may be difficult
- pulling tracheostomy tube through may damage vocal cords
- only able to insert one size of tube
- need to use a different technique to change type of tube
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
