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

FURTHER READING


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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