Use Bronchoscopic Guidance for Bedside Percutaneous Dilatational Tracheostomy (PDT)
Susanna L. Matsen MD
Elliott R. Haut MD
Percutaneous dilatational tracheostomy (PDT) has quickly become the standard method for conversion from short-term endotracheal intubation to tracheosotomy for longer-term mechanical ventilation. The procedure can be safely performed in the ICU, avoiding transport of critically ill patients to the operating room. The performance of a bedside PDT is contingent upon safety-minded advanced planning and a coordinated team effort. Given the inherent risks to the procedure, thoughtful preparation is essential. In the best case, a bedside tracheostomy proceeds smoothly; in the worst case it can end in tragedy.
Although some providers perform bedside PDT without direct visualization, most have now adopted the protocol of using direct bronchoscopic visualization. Before starting this procedure, adequate personnel must be assembled. One person is designated to manipulate the flexible bronchoscope and stands at the head of the bed. A second person is chosen to maintain control of the airway during manipulation of the endotracheal tube. Another person should be in charge of sedation, anesthesia, and monitoring. One or two people are dedicated to performing the tracheostomy itself.
There is no one best surgical technique for performing bedside percutaneous tracheostomy. A commonly used technique is the sequential dilation technique (i.e., Blue Rhino by Cook). The following steps are used by many surgeons experienced at this technique:
Position the patient by placing a rolled sheet beneath the shoulders to extend the neck and expose its anterior structures.
Place a bedside table above the patient’s torso and prep and drape the patient.
Test the tracheostomy balloon and lay out each instrument in the order in which they will be used.
After infiltrating local anesthetic, use the scalpel to make a vertical incision through the skin into the subcutaneous tissue (about 2 cm superior to the sternal notch).
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