Perioperative management - Percutaneous tracheostomy

• Long-term ventilation (> 10 days)

Advantages over intubation:

• no damage to the arytenoid cartilages
• Avoidance of mucosal lesions (nose/mouth, vocal cords, trachea)
• lower airway resistance (reduction of respiratory work)
• lower dead space
• better fixation
• better oral care
• reduced need for analgesics/sedatives
• higher patient comfort
• Facilitation of weaning from ventilation

• Emergency situations
• Indications of a difficult airway
• Significantly impaired or impossible conventional intubation
• Infections in the area of the puncture site
• Impaired anatomical conditions (e.g. large goiter, head not reclinable)
• Unstable C-spine
• Coagulation disorders
• Necessity of a permanent tracheostoma or the discharge of a tracheotomized patient to home > Creation of an epithelialized tracheostoma

• Determination of blood coagulation parameters
• Bronchoscopy

Fiberoptic monitoring of the tracheal puncture is strongly recommended.

• Bleeding
• Infection
• Injury to the Trachea
• Surgical Revision
• Pneumothorax
• Injury to the Recurrent Laryngeal Nerve
• Subcutaneous Emphysema (up to Mediastinal Emphysema)
• Scar Formation of the Tracheostoma

The procedure is performed on analgosedated and ventilated patients.

• Supine position with reclined head (so-called struma positioning)
• both arms adducted

Procedure that can be performed bedside in the intensive care unit!

The first assistant stands opposite the surgeon, the instrumenting OR nurse stands footward of the assistant on his side.

• Wash set
• Material set for percutaneous tracheotomy
• Bowl with NaCl
• Scandicain
• Epinephrine

for possible complications:

• Emergency cart with medications and conventional intubation set

• Bronchial hygiene: To keep the airways clear and avoid infections as well as atelectasis formation, the bronchial secretion in the ventilated patient must be suctioned endotracheally.
• Dressing change: The tracheostoma dressing should be renewed once daily – more often if heavily soiled. Every dressing change must be performed sterilely to avoid wound infection.
• Humidification of the breathing air: The tracheostomy tube bypasses or circumvents the upper airways. Their functions must be replaced by artificial measures. This primarily includes the warming and humidification of the inspiratory air
• Monitoring of cuff pressure: The cuff is intended to prevent inspiratory gas from escaping from the trachea during ventilation or liquid from entering the trachea. To avoid damage to the trachea, only tubes with low-pressure cuffs are used for long-term intubation. The cuff pressure can be measured with a special manometer and should be around 15-20 mmHg.
• Cannula change: After a tracheotomy, the cannula should be left in place for the first 48 hours, as no proper channel has formed yet. Thereafter, tracheostomy tubes are generally changed once a week.