Chapter 28

### Introduction

Percutaneous or surgical airways may be placed in patients in the intensive care unit for a variety of reasons including elective transition from an oral or nasal endotracheal tube to a chronic tracheostomy, or in emergency airway management (as described in Chapter 23). Alternative approaches include percutaneous tracheostomy and cricothyroidotomy.

### Definitions and Terms

• ▪  Larynx: The cartilaginous portion of the respiratory tract between the pharynx and the trachea, consisting of the cricoid cartilage, the thyroid cartilage and the arytenoids, the laryngeal muscles and the vocal cords (Figure 28-1)
• ▪  Cricothyroid membrane: A membrane between the thyroid cartilage and the cricoids cartilage
• ▪  Tracheostomy: Surgical creation of an opening from the skin into the trachea for the insertion of an artificial airway
• ▪  Cricothyroidotomy: Surgical creation of an opening between the skin and the trachea through the cricothyroid membrane
• ▪  Prolonged intubation: Oral or nasal intubation for a period exceeding several days—some evidence suggests that a percutaneous airway should be performed after 3 days of intuibation, whereas most would agree that it should be considered after 7 days

###### Figure 28-1.

Laryngeal anatomy.

### Techniques

• ▪  Indications
• —Prolonged intubation
• —Airway obstruction (supraglottic)
• —Pulmonary toilet
• —Obstructive sleep apnea
• —Emergency airway management
• ▪  Contraindications
• —Infection or surgical incision close to proposed insertion site
• —Coagulopathy
• —Distorted neck anatomy
• • Prior surgery
• • Thyromegaly
• • Neck trauma
• ▪  Patient should be consented for procedure, the site prepped and draped, and universal protocol performed as per Section I.
• —Percutaneous tracheostomy
• • The patient should be positioned with the neck extended (Figure 28-2).
• • Sedation should be administered as needed.
• • If the procedure is elective, a bronchoscope should be inserted through the existing endotracheal tube.
• • The tracheal rings should be palpated and the first and second rings identified.
• • The skin overlying these rings should be anesthetized with local anesthetic and a transverse (or vertical) 1.5 to 2 cm incision made in the skin and blunt dissection performed down to the tracheal cartilage (Figure 28-3).
• • Where feasible, a bronchoscope should be inserted into the trachea and to visualize insertion site, and the existing tracheal tube withdrawn (if applicable) far enough to permit simultaneous mechanical ventilation and endoscopic observation.
• • A narrow gauge needle (18–22) is inserted into the trachea, and midline position visually verified by endoscopic observation (bronchoscopically)—alternatively a needle through catheter can be inserted and the needle withdrawn (Figure 28-4).
• • A guidewire is inserted through the narrow gauge needle or catheter.
• • A series of dilators are then inserted over the guidewire under endoscopic visualization (Figures 28-5, 28-6, 28-7, 28-8, and 28-9).
• • The tracheostomy tube is inserted with the final dilator and the dilators and wire withdrawn (Figures 28-10, 28-11, ...

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