Bedside percutaneous tracheostomy is a common and safely performed elective procedure that was first described in 1985.^1,2,3 There are many variations to percutaneous dilatational tracheostomy (PDT),^4,5,6,7,8,9 and local expertise, patient characteristics, operator preferences, and equipment availability may drive the technique used for a particular patient. In this chapter, however, we focus on the modified Seldinger-based technique with bronchoscope guidance using a single tapering dilator. Ciaglia Blue Rhino (Cook Medical Inc., Bloomington, Indiana) (Fig. 32.1) and Portex ULTRAperc Single Stage Dilator Technique Kit (Smiths Medical., Dublin, Ohio) are common commercially available kits in the United States that provide a single tapering dilator. An accompanying video of the procedure being performed by the author supplements the text ( Video 32.1).

This procedure is most often performed in the intensive care unit to facilitate prolonged mechanical ventilation, airway hygiene, or to hasten weaning from sedation and mechanical ventilation. In some cases, percutaneous tracheostomy is performed early in the patient’s course for upper airway obstruction, or for neurologic recovery (e.g., traumatic brain injury). It is done at the bedside once the patient is deemed medically stable since there is transient loss of positive end-expiratory pressure (PEEP) and ventilation, and less frequently a brief period of apnea. In our practice, we prefer the PEEP to be below 10 cm H₂O and FiO₂ below 0.5, however, this procedure can be safely performed outside these parameters.¹⁰ Vasopressor dependence is not a contraindication for the procedure. Our data-supported practice is to hold therapeutic anticoagulation (usually continuous heparin infusions) for 4 hours prior to the procedure, but not prophylactic anticoagulation or any antiplatelets.^2,11 Direct oral anticoagulants may require at least 48 hours before the procedure. Obesity, inability to extend the neck, prior tracheostomy are only relative contraindications and PDT can be safely performed in these settings by experienced operators and with good patient selection.^12,13,14,15

Minimum adequate personnel includes the primary proceduralist, who performs the tracheostomy; bronchoscopist, who manages the airway and provides endoscopic guidance; respiratory therapist to primarily assist the bronchoscopist; and a bedside nurse to provide sedation and monitor the patient. Once the procedure is planned, informed consent is obtained, and adequate time-out for a safe procedure is completed.