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
- ▪ 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
- ▪ Indications
- —Prolonged intubation
- —Airway obstruction (supraglottic)
- —Pulmonary toilet
- —Obstructive sleep apnea
- —Emergency airway management
- ▪ Contraindications
- —Infection or surgical incision close to proposed
- —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
- —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tracheal tube withdrawn (if applicable) far enough to permit simultaneous mechanical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
- • 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, ...