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Percutaneous Tracheostomy

I. Overview

Patients with prolonged mechanical ventilation and endotracheal intubation are at risk for complications such as pneumonia, tracheomalacia, and subglottic stenosis. Tracheostomy offers a safer and more comfortable long-term airway option. Bedside percutaneous tracheostomy is a safe alternative to open surgical tracheostomy and reduces the need for patient transport and OR resources.

II. Purpose

  • To define indications and contraindications for tracheostomy
  • To describe the accepted protocol for bedside percutaneous tracheostomy

III. Patient Selection

A. Indications

  • Prolonged mechanical ventilation >7 days
  • Inability to protect airway (e.g., AMS, stroke, deconditioning)
  • Structural issues (e.g., severe facial fractures, unresolving airway edema)
  • Consider early tracheostomy (<7 days) for:
    • Severe TBI
    • Cervical spinal cord injury
    • TBI + submaxillary fractures
    • Laryngotracheal injury

B. Contraindications

  • <7 days post-op from anterior cervical fusion
  • High ventilator requirements:
    • FiO₂ > 60%
    • PEEP > 10
    • Incompatible with volume control ventilation
  • Elevated ICP
  • Hemodynamic instability

C. Special Situations

  • High-risk patients:

    • Morbid obesity
    • Airway edema
    • Cervical trauma
    • Halo brace/MMF
    • Extremes of age
    • High ventilator dependence, mucous plugging
    • Frequent desaturation
    • → Consider bronchoscopy guidance, ENT/OR backup, second proceduralist

  • COVID-19 patients (must meet all):

    • Cleared from isolation
    • PEEP <12
    • FiO₂ <80%
    • Must be performed by attending

  • BMI ≥ 35 → use Proximal XLT tracheostomy

D. Anticoagulation and Tube Feeds

  • Anticoagulation

    • Heparin drip: Hold 4 hrs pre- and post-procedure
    • Prophylactic heparin/enoxaparin: do not hold
    • Therapeutic enoxaparin: Hold AM dose, resume PM if no bleeding
    • DOACs: Hold 24 hrs pre-, resume PM if no bleeding
    • Aspirin: Do not hold
    • Clopidogrel/Ticagrelor/Effient: Do not hold
    • DAPT: Risk/benefit discussion required

  • Feeds

    • Hold ≥1 hour prior to procedure
    • May be held longer at ICU/intensivist discretion

IV. Procedure

A. Supplies

  1. Portex percutaneous tracheostomy kit (Blue Rhino for XLT)
  2. Mayo scissors (1)
  3. Curved hemostats (3)
  4. Needle holders (2)
  5. Army-Navy retractors (2)
  6. Tracheostomy tubes (#8 Portex + backups)
  7. Sterile towels, gowns, gloves
  8. Chlorhexidine skin prep
  9. 2-0 silk or monofilament sutures (2)
  10. Difficult airway cart/intubation set
  11. CO₂ detector
  12. Towel clamps (2)

B. Procedure Steps

  1. Sedation

    • Follow bedside sedation protocol
    • Recommend chemical paralysis + analgesia

  2. Setup & Timeout

    • Surgical prep per protocol
    • Preoperative timeout

  3. Tracheostomy Technique

    • Infiltrate skin with lidocaine + epinephrine
    • Make vertical incision 1–2 fingerbreadths above sternal notch
    • Blunt dissection to trachea in midline
    • Cut ET tube tape, retract ET tube under direct palpation to cricoid level
    • Complete tracheostomy via needle access and Seldinger technique

  4. Confirmation

    • Connect CO₂ monitor and confirm position by color change and exhaled volumes
    • Withdraw ET tube completely
    • Secure tracheostomy with sutures and neck strap
    • Obtain post-procedure chest X-ray

V. Downsize and Decannulation

A. Downsize

  • Criteria

    • POD 5

    • Tolerating ≥10 min trach collar trials
    • No further OR or bronch needs
    • Off vent & cuff deflation tolerated >48 hrs
      → Downsize to #6 non-cuffed XLT or #7 Portex

  • Supplies

    • Airway box and McGrath
    • Ambu bag, suction
    • Two new trachs
    • ETCO₂ detector, 10cc syringe, trach tie, lubricant
    • Suction catheter

  • Techniques

    1. Obturator/fish hook:
      • Remove trach → insert obturator with trach → advance at 90° angle → remove obturator → insert inner cannula
    2. Seldinger with suction catheter:
      • Insert suction catheter through current trach → remove old trach → guide new trach over catheter → confirm ETCO₂ and suction pass

  • Document general procedure note

B. Decannulation

  • Criteria

    • Off vent >72 hrs
    • Tolerating PMV or capping
    • No pending surgery or need for positive pressure
    • Managing secretions independently

  • Post-removal Care

    • Cover stoma with tightly taped dry dressing
    • Change dressing twice daily

VI. References

  1. Anand T, et al. J Trauma Acute Care Surg. 2020;89(2):358–364
  2. Brass P, et al. Cochrane Database Syst Rev. 2016;7:CD008045
  3. de Franca SA, et al. Crit Care Med. 2020;48(4):e325–331
  4. Dennis BM, et al. J Am Coll Surg. 2013;216(4):858–865
  5. Jackson LS, et al. J Trauma. 2011;71(6):1553–1556

VII. Authors

  • Christian Carpenter, RN
  • Elizabeth Krebs, MD
  • Michael C. Smith, MD
  • Brad Dennis, MD

Revised: February 2019, October 2021, February 2024, June 2024