Percutaneous dilatational tracheotomy

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Anterior triangle of the neck

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    Situated between the anterior margin of the sternocleidomastoid muscle, the mandibula und the jugular fossa, the anterior cervical triangle near the hyoid bone comprises the suprahyoid and subhyoid muscles, vessels, nerves and the thyroid.

    Fascial layers

    The skin of the anterior triangle of the neck covers several fascial layers (all belonging to the cervical fascia) with distinctive features:

    • The superficial lamina invests all structures of the neck, except for the platysma, and separately invests the sternocleidomastoid muscle as well as the posterior aspect of the trapezius muscle (accessory nerve XI),
    • with the medial pretracheal lamina investing the subhyoid muscles and
    • the deep prevertebral lamina coursing outside the surgical field between the esophagus and spine.

    Just like the lateral vascular and nerve pedicle (carotid artery, internal jugular vein and vagus nerve), the trachea and thyroid / parathyroids also have their own organ fascias. With their three-dimensional configuration, the fascias invest compartments interspersed with spaces which extend into the mediastinum and thus represent potential routes of infection.

  • St. Katharinen Hospital Frechen

    Prof. Dr. med. Christoph Diefenbach

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 06.04.2009
  • St. Katharinen Hospital Frechen

    Prof. Dr. med. Christoph Diefenbach

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  • Local anesthesia of the surgical field

    43-4

    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.

  • Bronchoscopic overview

    43-5

    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.

  • Tracheal puncture and introduction of the Seldinger guidewire

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    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.

  • Skin incision and insertion of the dilator

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    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.

  • Dilating the pretracheal tissue

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    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.

  • Dilating the trachea under bronchoscopic monitoring

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    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.

  • Inserting and fixating the tracheotomy tube

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    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.

  • Bronchoscopic verification of tube position

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    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.

  • St. Katharinen Hospital Frechen

    Prof. Dr. med. Christoph Diefenbach

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  • Intraoperative complications

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  • Postoperative complications

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  • Praxis für Chirurgie & Gefäßchirurgie

    Dr. Helmut Nigbur

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  • Literature summary

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  • Textbooks and metaanalyses

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  • References on this topic

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  • Literature search

    Literature search under: http://www.pubmed.com