This is bronchoscopy-guided percutaneous tracheostomy. In this video, we are going to review the head and neck anatomy that is relevant to the placement of a percutaneous tracheostomy. We will also review the step-by-step procedure to placing a bedside percutaneous tracheostomy tube. We will discuss any potential complications and also walk you through how to handle an accidental decannulation. I'm Laura Frey. I'm a faculty at the University of Wisconsin, and I'm a member of the Bronchoscopy Domain Task Force. Hi. I'm Jorge Morgon. I'm a faculty at the University of Chicago, and I'm the current chair of the Education Committee for CHEST. Hi. I'm Dolores Reyes. I'm a faculty at Roslyn Faculty University, and I am at the Subcommittee for Innovation and Education Committee of CHEST. We are going to quickly review the key components that you'll have in your Cooke percutaneous tracheostomy tray. These are the key components that you will need for your procedure. This begins at the process of sterilization. So in each kit, you will have a chloroprep, though we would recommend that you grab additional chloropreps to ensure appropriate sterilization of your field. You also have a drape within the kit and multiple 4x4s for keeping your field clean and dry. You then have a trach kit, a Shiley trach kit that corresponds to the size of the percutaneous trach that you are going to place. Since this is a 6-0 perc trach kit, we have a 6-0 trach. If you were placing an 8-0 perc trach, this would then be an 8-0 trach. Inside each kit, you will have the operator and hard ties. We also have our trach where we want to ensure that we have a functioning cuff and pilot balloon before we start our procedure. To do so, we will inflate our cuff, and we see that we have a good function before we proceed with the rest of our procedure. Our kit also includes a filter needle to draw up lidocaine with epinephrine, as well as small needles that will assist with local analgesia. We then have two different needles that function for the tracheocentesis, as well as one needle that has a catheter as well. Through these needles, we will pass our guide wire, which will then secure our location in the airway prior to making an incision and then proceeding with dilation. To proceed with the dilation, we have multiple dilators that you will see on the tray here. The smallest is a 14 French dilator, which is a punch dilator that will create a small opening in the trachea before proceeding with your small dilators and ultimately your large cone dilator. These small dilators will pass through your trach to allow passage of the tracheostomy tube at the end of the procedure. You may notice that there are three dilators in the kit. That is because each of them corresponds to the size of the tracheostomy tube that you are placing. In this setting, we are placing a 6-0 trach, so we are going to use the 26 French loading dilator. The last digit of each dilator corresponds to the trach size we are placing. We will load this through the tracheostomy tube so that it is flush and we are able to place our trach at the end of the procedure. We also have our cone dilator, or our blue rhino, as well as a stiffening catheter that will create our pathway for our tracheostomy tube. Once our tracheostomy tube is in place, we will secure it with suture and then using a new bronch adapter, we will be able to pass our bronchoscope and ensure adequate position of our tracheostomy tube before withdrawing our endotracheal tube from the patient's airway. Prior to proceeding with a percutaneous tracheostomy tube placement in a mechanically ventilated patient, there are a few key points that we want to assess to ensure that our patient is ready for this procedure and able to tolerate from both a respiratory and a hemodynamic standpoint. We want to assess our patient's ventilator settings to ensure that they are on a low stable vent setting. This could be something such as an FIO2 of 60% and a PEEP of less than 10. We also want to ensure that our patient is able to tolerate ICU sedation at a level that we would be able to sedate them to tolerate neuromuscular blockade without any issues with hemodynamic compromise. For patient positioning, we are going to focus on neck extension as well as retraction of the shoulder blades. This allows us to expose the neck anatomy that will be essential to view for the placement of our percutaneous tracheostomy tube. For retraction, also potentially displaces hyperinflated lung tissue to avoid lung puncture. For identification of placement of the percutaneous tracheostomy tube, we will evaluate our extended patient's neck anatomy. We will begin by identifying our thyroid cartilage and then marching down the neck, identifying the cricoid and the tracheal rings. We will continue to identify the rings until we reach the level of the notch, knowing that ideally we will place our percutaneous tracheostomy tube between ring two and three. As we palpate, we will also be focusing on whether or not we palpate any pulsatile vessels as there is the potential for a high-riding anominate artery. There's any concern for vascular structures in our field, you have the option of using ultrasound for a closer evaluation. Prior to selecting our tracheal entry site, we will reposition our cuffed endotracheal tube. The bronchoscope is loaded in the trachea distal to the endotracheal tube and we will withdraw the bronchoscope into the endotracheal tube to the level of the Murphy's eye. We will then deflate the cuff of the endotracheal tube and under direct visualization, we will withdraw the endotracheal tube to the level of the subglottis. Using the Murphy's eye, we can reach the vocal cords and pause to identify our landmarks. If we now advance our scope, we can see the cricoid with direct palpation and our tracheal rings below. If possible, the endotracheal tube will be positioned such that we have a 360-degree view of the airway. The cuff is now reinflated and we are prepared to proceed with our procedure. Prior to sterilizing our field, we will again re-identify our anatomy, palpating our thyroid cartilage, our cricoid cartilage, and our endotracheal tube. Palpating our thyroid cartilage, our cricoid cartilage, and the first and second tracheal rings. Once we've identified our site, we will now proceed with sterile prep with chlorhexidine. Once our field has been sufficiently prepped, we will allow the chlorhexidine to dry and place a sterile drape. The sterile drape will be extended up to cover our endotracheal tube. And then down to cover our patient's torso. Once our sterile field is in place, we will now proceed with local analgesia with lidocaine with epinephrine. This will be administered subcutaneously in four quadrants. You can see Dr. Mergu demonstrating the four quadrant technique here. Aspirate as I go in, make sure I don't puncture the vessel, and inject as I retract the needle. Aspirate as I go in, and retract, and inject. Using a small bore needle, you will begin to identify your entry site. This will occur by identifying the cricoid with palpation, and then moving distal to identify the site between the second and third tracheal rings. Higher locations should be avoided due to the risk of tracheal stenosis. You can go between the third and fourth tracheal rings if needed, but we would discourage any more distal placement due to the risk of injury to the anominous. Once the small needle is bronchoscopically confirmed in an acceptable location, the large bore needle is introduced adjacent to it, and the small needle is removed. For the tracheosthesis, the large bore needle or an angiocast may be used. Maintain bronchoscopic visualization during this to avoid injury to the posterior tracheal walls. Once the large bore needle is inserted, the small bore needle is removed, and the large bore needle is rotated so that a guide wire can be advanced distally into the trachea. Again, under direct visualization, the guide wire is advanced through the large bore needle. Once the guide wire has been advanced, the large bore needle can be withdrawn. This is incision. We will now proceed with placing an incision one centimeter above and one centimeter below our guide wire. This incision will be done to the level of the subcutaneous fat. We are demonstrating a vertical incision in this video. Again, one centimeter above and one centimeter below. Some proceduralists prefer to make a horizontal incision, as this can be hidden in the skin folds of the neck. We are also demonstrating an incision after the placement of the guide wire, in the event that your entry site cannot be identified. There are, however, individuals who proceed with an incision prior to accessing the entry site and placement of their guide wire. A quick tip, the incision should indeed be 1.5 to 2 centimeters, because if it's too small, the skin may be too tight and hold the dilator, which may result in too much force over the cartilage and potential cartilage fracture. Once your incision is complete, you want to ensure that you have free movement of your guide wire. Now that we've made our incision, we will proceed with the initial dilation of the subcutaneous and intercartilaginous space using a punch dilator. Using the small 14 French dilator, under direct visualization, we will dilate the space between the second and third tracheal rings. The punch dilator is now withdrawn, and we will proceed with our cone dilator over the stiffening catheter and guide wire. It is important that these have been lubricated prior to insertion. The cone dilator and the stiffening wire are inserted and blocked over our guide wire. And under direct visualization, we are watching for the thick black line to be visible within the airway. Maybe. I don't think. Maybe too much. A little more in there. Yeah. Once the thick black line is visualized in the airway, we can remove the dilator, but leave the guide wire and the stiffening catheter. Okay. Now that we've performed our dilation and our stiffening catheter and our guide wire in place, we are ready to proceed with insertion of our tracheostomy tube. A loading dilator is advanced into the tracheostomy tube so that no gap is present between the distal aspect of the trach and the loading dilator. Again, the loading dilators correspond to the size of your tracheostomy tube, so if you're replacing a 6-0 tracheostomy tube, you will use a 26 French loading dilator. The trach is now inserted over the guide wire and the stiffening catheter. The trach insertion occurs under direct visualization with the trach inserted until the cuff is visualized in the airway. Once the cuff is completely inside the airway and confirmed bronchoscopically, the guide wire, stiffening catheter, and dilator are removed and blocked. The trach is now inserted over the guide wire and the stiffening catheter. The trach insertion occurs under direct visualization with the trach inserted until the cuff is visualized in the airway. The guide wire, stiffening catheter, and dilator are removed and blocked. The inner cannula can now be placed inside the tracheostomy tube. We can also now transition our ventilator from the endotracheal tube to the tracheostomy tube and proceed with cuff inflation. Switch ventilation, please. Switch ventilation, please. Now that our tracheostomy tube has been inserted, we will confirm the location of our tracheostomy tube and then proceed with removal of the endotracheal tube. Due to our use of a large bronchoscope and the placement of a 6-0 tracheostomy tube, we will be unable to use the swivel adapter and as such have removed the inner cannula and will proceed with inspection of the airway and aspiration of any hemorrhagic secretions. Once clearance of secretions has been achieved, we will measure the distance from the carina to the tip of our tracheostomy tube. From the carina to the tip of our tracheostomy tube. Once this distance has been measured, the scope will be withdrawn and the inner cannula reinserted. We will now proceed with bronchoscopic guided removal of the endotracheal tube and measurement of the distance from the stoma to the vocal cords. The bronchoscope is now reinserted through the cupped endotracheal tube for evaluation of the larynx. We will now measure the distance from the stoma to the cords. Deflating the cup. Pulling back the tube. Let's do the measurement, Dr. Larray. Okay. From the stoma. Backing up. Larynx. Cords. Cords. 5 centimeters. Any abnormal laryngeal findings can also be documented in our notes. Now that we've confirmed the location of our tracheostomy tube, we will secure the tube in place. Soft or hard ties can give a false sense of security, and as such, we recommend placement of four stitches over the tracheostomy flange to secure this to the skin. Dr. Mergo is demonstrating the suturing technique. So in four quadrants, not too tight to the skin, because too much pressure from the flange could cause skin necrosis. Some people actually prefer to use a dilator or the stiffening catheter while doing this to avoid too much tension. And now we're cutting. We would then proceed with placing three additional stitches in the remaining three quadrants. You are called to a patient's bedside 24 hours after percutaneous tracheostomy placement. Sutures are not in place, and the soft ties are loose with dislodgement of the tracheostomy flange as seen here. We are going to demonstrate the technique for now securing this patient's airway. Given the risk of fistula formation, we would discourage you from re-advancing the tracheostomy tube, as this is a fresh stoma and it is unclear whether or not you will truly enter the patient's airway. Following administration of appropriate sedation and analgesia, we would recommend proceeding with a direct laryngoscopy or a fiber optic intubation. Bypassing the stoma, the lower trachea, and advancing the endotracheal tube over the bronchoscope. And securing it at five centimeters above the larynx. Inflate the cuff. We'll be covering the stoma now with a gauze. Wet gauze can now be used to cover the stoma and ensure appropriate ventilation without significant air leak.

percutaneous tracheostomy tube

bronchoscopy guidance

head and neck anatomy

complications

accidental decannulation

ventilator settings