Percutaneous dilatational tracheotomy - general and visceral surgery

Anesthetize the skin at the planned tracheotomy site with mepivacaine 1% and 1:100,000 epinephrine (about 5 ml).

The skin will become ischemic and turn white; this will lessen any bleeding.

Tracheal assessment Pull back the ventilation tube to the level of the vocal cords.

Transilluminate the site of the planned puncture from the lumen of the trachea with the light of the bronchoscope.

Puncture in a strictly median and slightly caudad direction.

Concurrent bronchoscopic monitoring helps prevent puncture of the posterior tracheal wall or the cuff of the endotracheal tube and verify the correct position of the puncturing needle.

When air is aspirated into the syringe, the needle is within the tracheal lumen.

Gain access through a horizontal skin incision of about 1.5 cm through which the tracheotomy tube will be introduced later.

Do not leave any skin bridges near the Seldinger guidewire.

Now gently screw down the plastic dilator over the guidewire until it stops and then remove it immediately.

Insert special dilating forceps over the guidewire and sufficiently dilate the pretracheal tissue. Remove the forceps. While some bleeding may be seen from the soft tissues, this will usually stop once the tracheostomy tube has been inserted.

Re-introduce the forceps over the guidewire and advance under bronchoscopic monitoring into the tracheal lumen; carefully open the branches until they rest against the tracheal wall.

Sparingly coat the tracheotomy tube with topical xylocaine and insert it into the trachea under gentle pressure and with a rotating motion; then block the cuff.

Attach the ventilator.

The tracheotomy tube is anchored with interrupted sutures and covered with sterile keyhole dressings.

As final step bronchoscopically verify the tube position, rule out tracheal injury and suction any blood and secretions.

Note: While the cuff is deflated, the bronchoscope may be advanced through the larynx along the outside of the tracheotomy tube until it reaches the tracheal bifurcation; during retraction, the entire length of the posterior membranous wall can be inspected.