Dr. T. Balasubramanian M.S.
Since the advent of open tracheostomy efforts
were made to devise a procedure which will enable access into the
trachea without a surgical incision or a minimal surgical incision.
Percutaneous tracheostomy was devised with just this purpose in
Advantages of percutaneous tracheostomy:
1. It is a simple procedure
2. Very easy to perform under emergency
3. Can be performed easily on the bed
4. Can be performed by paramedics
Evolution of percutaneous tracheostomy:
The first tracheostomy technique that did not
require neck dissection was first described by Sheldon in 1957. He
used a specially designed slotted needle to blindly enter the
tracheal lumen. This needle served as a guide for the introduction
of a stillete and a metal tracheostomy tube.
In 1969 Toyee refined this technique making it
incisional rather than dilational. In this technique after the
trachea was cannulated using a needle, the tracheostomy tube was
loaded on to a stiff wire boogie that contained a small recessed
blade. This boogie along with the tracheostomy tube was advanced
through the needle tract thereby placing the tracheostomy tube
inside the trachea. This procedure was fraught with risks and para
tracheal insertions occurred commonly and hence did not become
In 1985 Ciaglia perfected the technique of
percutaneous tracheostomy which is currently gaining popularity. He
named this procedure dilational subcricoid percutaneous
tracheostomy. (PDT). This technique has undergone three significant
1. The tracheal interspace for cannulation has
been moved down by two rings caudal to the cricoid cartilage. This
was done to prevent the development of subglottic stenosis.
2. Routine use of fibreoptic bronchoscopy has
3. The use of single bevelled dilator has been
substituted by the use of multiple dilators.
The vital signs of the patient are continuously
monitored during the procedure. The patient is ventilated with 100%
oxygen during the whole procedure. The patient is sedated using a
narcotic analgesic, and often a non depolarising neuromuscular
blocker is used. The neck of the patient is extended to bring up the
trachea closer to the skin. The vertex of the patient is properly
A 2 cm skin incision is located at the level of
1st and the 2nd tracheal rings. The wound is then dissected bluntly
using artery forceps. The existing endotracheal tube is then slowly
withdrawn to a level just above the first tracheal ring, the needle
is then inserted through the incision to penetrate the trachea
between the second and the third tracheal rings. The J tipped guide
wire is inserted through the needle till it hits the level of
carina. The needle is then withdrawn. Bevelled plastic dilators are
introduced over this guide wire and the opening is dilated to create
a tracheostome. When the dilatation is adequate a special
tracheostomy tube is inserted over the guide wire. The dilators can
be used as obturators. In properly performed precutaneous
tracheostomy the tracheostomy tube will pass
through the isthumus of the thyroid, there will not be any
significant bleeding because the procedure is purely dilatational.
Paul's modification of Ciaglia
This modification was introduced in 1989. Paul
advocated the use of fibreoptic bronchoscope through the
endotracheal tube to facilitate percutaneous tracheostomy.
The advantages of this modification are:
1. Use of bronchoscope allows for correct
placement of tracheostome.
2. It ensures that the guide wire is introduced
in a midline position.
3. It prevents damage to posterior tracheal wall
during introduction of needle.
4. It helps in video recording the whole
procedure for instructional purposes.
The major disadvantages of this modification
1. It involves more time.
2. More trained personal and special equipments
3. The procedure is more expensive.
To reduce the operating time a single curved
dilator (Blue rhino dilator) is utilised instead of multiple
dilators. Since this dilator is soft and has a more physiologic
curvature it does not cause extensive damage to the soft tissues and
the tracheal walls.
Rapitrach technique: This
was first introduced in 1989 by Sachachner with an intention in
facilitating a rapid tracheostomy. A special Rapitrach dilator was
used. A rapitrach has two sharp blades designed in such a way that
it slides over the guide wire and an opening is made when it is
dilated. This procedure had a high incidence of damage to the
membranous posterior tracheal wall. To avoid this complication in
1990 Griggs used a custom made forceps known as the Howard Kelly
forceps. The tip of the forceps can be opened to create a
tracheostome. In fact in all these methods the basic steps are the
same but for modifications in the dilatation
Translaryngeal tracheostomy: This was first
describe by Fanconi etal. The major aim of this procedure is to
prevent damage to the posterior membranous wall of the trachea. The
dilatation in Ciaglia technique is directed in a downward direction
causing significant anteroposterior compression of the tracheal
wall. Sometimes this compression is sufficient to cause rupture of
the membranous posterior tracheal wall. In this technique this
excess anteroposterior pressure is avoided since the tracheostomy
tube is pulled upwards through the larynx in an inside out manner.
The procedure is similar to Ciaglia technique till the introduction
of a guide wire through the first and the second tracheal
interspaces. The similarity ends here. The guide wire is passed
through the needle into the larynx in a retrograde fashion, infact
it traverses coaxially alongside the endotracheal tube till it
reaches the oral cavity from where it is pulled out using a Magill's
forceps. The aim of the next step is to create a room for the
tracheostomy tube to traverse the larynx since an endotracheal tube
is already in position. To achieve this the existing endotracheal
tube in position is replaced with a smaller endotracheal tube using
the same guide wire as a guide. The J tip (oral cavity end) of the
guide wire is then attached to a special trocar and tracheostomy
tube assembly. The guide wire is pulled through its neck end. This
pulls the trocar along with the tracheostomy tube through the larynx
into the trachea. Here excessive tension to the posterior tracheal
wall is avoided. When the trocar causes tenting of skin in the neck
a small incision is made over this tenting and the trocar is
delivered out along with the tracheostomy tube. The endotracheal
tube is removed, and the tracheostomy tube is anchored in
Since these procedures involve an already
intubated patient it calls for excellent coordination between the
surgeon and the anaesthetist.
Routine pre operative ultrasound examination of
the neck is a must because it will identify the site of an unusually
large inferior thyroid veins which could cause troublesome bleeding
during the procedure.
1. A patient already in intense stridor.
2. Laryngeal malignancies
3. Short neck individuals
4. When proper trained personal are not
5. Large thyoid gland
6. When ultrasound reveals an abnormally large
inferior thryoid vein.
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