Key Point:

Modified percutaneous tracheostomy can be performed employing digital palpation to guide placement of the catheter, eliminating the need for bronchoscopy in most cases.

TEL AVIV—In 1985, Ciaglia et al proposed a percutaneous dilational technique for tracheostomy that was safer and simpler than previous surgical methods. In 1990, Griggs et al introduced a technique using a guidewire dilating forceps. Bronchoscopic guidance is recommended with both techniques. However, bronchoscopes have drawbacks, including cumbersome instrumentation that can interfere with maintenance of the airway or even result in airway loss.

Recently, a team of Israeli surgeons demonstrated a technique modification using blunt dissection of the subcutaneous and pretracheal tissues, with manual palpation of the trachea instead of bronchoscopy to guide placement of the catheter. They used the technique in 61 consecutive tracheostomies performed at their hospital and found that it is simple, easy for surgeons to learn, and safe.¹

All patients required a tracheostomy due to prolonged mechanical ventilation. The procedure was performed at bedside, with no need to transport the patients to another facility. One attending surgeon performed the operation with the assistance of an anesthetist or surgical resident, depending on hospital department.

THE PROCEDURE

With the patient supine and neck slightly hyperextended, a midline vertical 2-cm incision was made just above the suprasternal notch to allow insertion of the operator’s index finger through the incision. After subcutaneous tissues were dissected bluntly down to the pretracheal fascia, the trachea was manually palpated. Using manual palpation as guidance, the endotracheal tube cuff was deflated and retracted. The retraction of the tube could be easily felt with a finger, and then the cuff was reinflated.

After the angiocatheter was inserted into the trachea between the second and third tracheal rings, again using the operator’s finger for guidance, airflow into the syringe confirmed the correct placement of the angiocatheter tip. At this point the guidewire was introduced through the cannula, and the dilator was advanced over the wire. During the procedure, the wire was firmly anchored so that it did not cause injury to surrounding structures. A dilator was then advanced into the opening of the anterior trachea and the tracheotomy tube was inserted. Placement was confirmed either by measuring end-tidal volume carbon dioxide or by measuring end-expiratory volume in the respirator. The tube was then sutured in place.

Persistent bleeding from subcutaneous rupture occurred in one patient. No other perioperative complications occurred that were related to the procedure, and the airway was maintained in all patients.

SURGICAL EXPERIENCE HELPFUL

“The technique is indeed simple, when performed by surgeons with experience in neck operations,” said lead author Haim Paran, MD, Senior Staff Surgeon at Meir Medical Center in Kfar-Sava, Israel. In fact, after the first 10 procedures, the remaining tracheostomies were performed by residents under the attending surgeon’s guidance, demonstrating the ease with which the procedure can be learned. “Using blunt dissection of tissues until the tracheal fascia is reached, and then digitally palpating the tracheal rings, it is easy to place the needle in the right place and avoid damaging surrounding structures,” he explained.

Although the modified percutaneous technique uses a smaller incision than the classical surgical tracheostomy, Dr. Paran, who is also a lecturer at Tel Aviv University Medical School, pointed out that certain patient types—for example, obese patients or those with short necks or large thyroid glands—may still require a larger incision to ensure that the procedure is done safely.

The use of bronchoscopy during percutaneous tracheostomy is still a subject of debate. “As far as I know, percutaneous tracheostomies are still performed with bronchoscopic guidance in most settings, because bronchoscopy is advocated by the manufacturers of tracheostomy kits, and the procedure is usually done by personnel without surgical skills, who are not comfortable with dissection of the subcutaneous tissues of the neck,” observed Dr. Paran. However, if the operation is performed without dissection, he added, “then bronchoscopy is still needed, since without it the trachea can be missed. Also, the puncture of the trachea, if done too high, can result in late complications.”

—Gale Jurasek

Reference
1. Paran H, Butnaru G, Hass I, Afanasyv A, Gutman M. Evaluation of a modified percutaneous tracheostomy technique without bronchoscopic guidance. Chest. 2004;126:868-871.

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