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 Principles and Practice of
Percutaneous Tracheostomy
 Principles and Practice of
Percutaneous Tracheostomy

Sushil P Ambesh
Professor and Senior Consultant
Department of Anaesthesiology
Sanjay Gandhi Postgraduate Institute of Medical Sciences
Lucknow (India)

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

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Published by
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Jaypee Brothers Medical Publishers (P) Ltd
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Principles and Practice of Percutaneous Tracheostomy

© 2010, Jaypee Brothers Medical Publishers (P) Ltd.

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or
transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise,
without the prior written permission of the editor and the publisher.

This book has been published in good faith that the material provided by contributors is original.
Every effort is made to ensure accuracy of material, but the publisher, printer and editor will not be
held responsible for any inadvertent error (s). In case of any dispute, all legal matters are to be
settled under Delhi jurisdiction only.

First Edition: 2010

ISBN 978-81-8448-929-3
Typeset at JPBMP typesetting unit
Printed at
 Contributors
Alan Šustić Guido Merli
Professor of Anaesthesiology and Intensive Care Department of Anaesthesia and
Department of Anaesthesiology and Intensive Care Intensive Care Medicine
University Hospital Rijeka, T. Strizica 3, 51000 Centro Cardiologico Monzino
Rijeka, Croatia Milano, Italy
Antonio Fantoni Isha Tyagi
Professor of Anestesia e Rianimazione Professor of Otorhinolaryngology
Department of Anaesthesia and Intensive Care Department of Neurosurgery
San Carlo Borromeo Hospital Sanjay Gandhi Postgraduate Institute
Milan, Italy of Medical Sciences
Arturo Guarino Lucknow, India
Department of Anaesthesia and Intensive Care
Joseph L Nates
Medicine
Associate Professor, Deputy Chair
Villa Scassi Hospital,
Medical Director, Intensive Care Unit
Geneva, Italy
Division of Anesthesiology and Critical Care
Chandra Kant Pandey The University of Texas
Senior Consultant Anaesthetist MD Anderson Cancer Center
Sahara Hospital, Gomti Nagar Houston, TX, USA
Lucknow, India
Massimiliano Sorbello
Christian Byhahn Anesthesia and Intensive Care
Assistant Professor of Anesthesiology and Policlinico University Hospital
Intensive Care Medicine Catania, Italy
Department of Anesthesiology
Intensive Care Medicine and Pain Control Rudolph Puana
J W Goethe-University Medical School Assistant Professor
Theodor-Stern-Kai 7 Critical Care Department, Division of
D-60590 Frankfurt, Germany Anesthesiology and Critical Care
Donata Ripamonti The University of Texas
Department of Anaesthesia and Intensive Care MD Anderson Cancer Center
San Carlo Borromeo Hospital Houston, TX, USA
Milan, Italy Sushil P Ambesh
Giulio Frova Professor and Senior Consultant
Professor and Director Emeritus Department of Anaesthesiology
Department of Anesthesia and Intensive Care Sanjay Gandhi Postgraduate Institute
Brescia Hospital of Medical Sciences
Brescia, Italy Lucknow, India
 Foreword
The development of the percutaneous tracheostomy over the last two decades has revolutionized
tracheostomy in critically ill patients. It has become an established procedure facilitating weaning from
ventilatory support and shortening intensive care stay. Operative time is reduced and an operating theatre
is not required. The risk of transferring a critically ill patient from ITU to theatre is also eliminated. It
appears that long term sequelae are likely to be no more frequent than with surgical tracheostomy. There
is no doubt that the development of the percutaneous tracheostomy will have proved to have been a
major development in the management of critically ill patients.
In this context Principles and Practice of Percutaneous Tracheostomy written by professor Ambesh
and co-authors provides a comprehensive overview of this important topic. This volume introduces us
to the most recent developments in tracheostomy practice with a fascinating history of the origins of the
tracheostomy. A detailed description of the various techniques is included, as is a catalogue of complications,
contraindications and comparisons with surgical tracheostomy. The reader is taken through the practical
procedures for different percutaneous tracheostomy techniques step by step with generous clear
illustrations to guide him or her through the operation and avoiding potential difficulties and hazards.
Many practical tips are included reflecting a wealth of underlying experience. Every aspect of this core
topic in critical care medicine is covered.
As former colleagues of Professor Ambesh we are honored and delighted to write a foreword for
this fine textbook, which not only teaches and instructs but also provides a fascinating insight into one
of our most recently developed techniques in intensive care medicine. We have had first hand experience
of the authors’ skill and expertise, not just in the field of percutaneous tracheostomy but also his
considerable clinical knowledge and abilities as an intensivist. It is with great pleasure that we recommend
this outstanding textbook on the principles of percutaneous tracheostomy, which will prove to be an
invaluable resource for all those involved in critical care.

TN Trotter and ES Lin

University Hospitals of Leicester, UK
 Preface
Tracheostomy is one of the most commonly performed surgical procedures in intensive care unit
patients and is indicated when airway protection, airway access or mechanical ventilation are needed for
a prolonged period. Tracheostomy also facilitates weaning from the ventilator. Since its inception
tracheostomy has remained in the domain of surgeons. Many a times the anesthesiologists or intensive
care physicians looking after these patients get frustrated due to non-availability of the surgeon, operation
room or encountered difficulties in shifting critically ill patients to operation room. This may have
delayed timely formation of tracheostomy in needy patients. Anesthesiologists are supposed to be master
in the art of airway management; however, dependency on surgeons to establish airway by surgical
means gives a sense of incompleteness. With the advent of percutaneous dilatational tracheostomy
(PDT), a bedside procedure, another much needed tool in airway management has been added in the
armamentarium of anesthesiologists and intensive care physicians. Not only this, the PDT is gradually
proving its superiority over surgical tracheostomy in many ways.
Over the last two decades surgical tracheostomy has largely been replaced by the PDT and more and
more such procedures are being carried out worldwide. In early 1990s, when I was working as Anesthetic
Registrar at Ulster Hospital, Dundonald, UK, my esteemed consultant Dr JM Murray, MD, FFARCSI
taught me this procedure and I owe everything to him about this wonderful art of minimally invasive
airway access. At that time, there were only two types of percutaneous tracheostomy kits: the Ciaglia’s
multiple dilators and Griggs guidewire dilating forceps. Presently, a number of PDT kits and techniques
are available for clinical use and it is likely that further developments will take place in this field of airway
access.
Advancement in readily available techniques of bedside percutaneous tracheostomy has carried
respiratory therapy to a heightened level. Regrettably, many physicians remain ignorant of these clinically
relevant advances and management of percutaneous tracheostomy and tracheostomized patients.
Therefore, it is prudent to provide thorough knowledge of this important procedure to our trainees and
colleagues who have been working in the field of anesthesia, intensive care unit, high dependency unit
and pulmonary medicine. In this book I have tried to include all important and different PDT techniques
available at present. There are various chapters written by guest authors’ who have immensely contributed
to the development and refinement of this novel technique. I sincerely hope that this comprehensive text
on percutaneous tracheostomy alongwith relevant illustrations and pictures will be useful to the consultant
anesthesiologist, intensivist, internist, chest physician, ENT surgeons and trainee residents.

Sushil P Ambesh
 Acknowledgments
To my beloved wife Shashi and my two sons Paurush and Sahitya, without their constant encouragement,
understanding and love this work could not have been possible.
To my loving parents IL Ambesh and Shanti Devi who taught me good social values, inspired me to
become a doctor and have always been a constant source of inspiration.
To my revered teacher Dr JM Murray, MD, FFARCSI, Consultant in Anaesthesia and Intensive Care
at Ulster Hospital, Dundonald, Belfast (UK) who taught me the art of minimally invasive airway management
in early 1990s, when it was in its inception days.
My thanks are due to all the guest authors who have contributed many important chapters with high
level of scientific and clinical knowledge. Their participation was fundamental to define the style of this
publication. Special thanks with gratitude to Dr Matthias Gründling, Consultant Anesthetist and Intensivist
at University of Greifswald, Germany who has provided a number of rare photographs from Archives
of Anatomy, Greifswald.
My sincere thanks to Dr PK Singh, Professor and Head, Department of Anesthesiology, Sanjay
Gandhi Postgraduate Institute of Medical Sciences, Lucknow (India) who has always encouraged and
facilitated my scientific and academic endeavors.
 Contents
1. History of Tracheostomy and Evolution of Percutaneous Tracheostomy ............................ 1
Sushil P Ambesh
2. Anatomy of the Larynx and Trachea ..................................................................................... 12
Sushil P Ambesh
3. Indications, Advantages and Timing of Tracheostomy ........................................................ 18
Sushil P Ambesh
4. Standard Surgical Tracheostomy ............................................................................................ 23
Isha Tyagi, Sushil P Ambesh
5. Cricothyroidotomy.................................................................................................................... 29
Giulio Frova, Massimiliano Sorbello
6. Ciaglia’s Techniques of Percutaneous Dilational Tracheostomy ........................................ 39
Rudolph Puana, Joseph L Nates, Sushil P Ambesh
7. Griggs’ Technique of Percutaneous Dilational Tracheostomy ............................................ 49
Sushil P Ambesh
8. Frova’s PercuTwist Percutaneous Dilational Tracheostomy ................................................ 56
Giulio Frova, Massimiliano Sorbello
9. Fantoni’s Translaryngeal Tracheostomy Technique ............................................................. 65
Donata Ripamonti
10. Balloon Facilitated Percutaneous Tracheostomy .................................................................. 80
Christian Byhahn
11. Percutaneous Dilatational Tracheostomy with Ambesh T-Trach Kit .................................. 84
Chandra Kant Pandey
12. Anesthetic and Technical Considerations for Percutaneous Tracheostomy ...................... 89
Sushil P Ambesh
13. Complications and Contraindications of Percutaneous Tracheostomy ............................ 101
Sushil P Ambesh
14. Percutaneous Dilational Tracheostomy in Special Situations ............................................ 111
Sushil P Ambesh
15. Percutaneous Tracheostomy versus Surgical Tracheostomy ............................................ 116
Arturo Guarino, Guido Merli
 xiv Principles and Practice of Percutaneous Tracheostomy

16. How to Judge a Tracheostomy: A Reliable Method of Comparison

of the Different Techniques .................................................................................................. 124
Antonio Fantoni
17. The Need to Compare Different Techniques of Tracheostomy
in More Reliable Way ............................................................................................................ 130
Antonio Fantoni
18. Care of Tracheostomy and Principles of Endotracheal Suctioning ................................... 136
Sushil P Ambesh
19. Ultrasound-guided Percutaneous Dilatational Tracheostomy ........................................... 149
Alan Šustić
20. Tracheostomy Tubes, Decannulation and Speech ............................................................... 155
Sushil P Ambesh

Index .................................................................................................................................................. 163

 Tracheostomy Tubes, Decannulation and Speech xv

Abbreviations
ABP Arterial blood pressure ID Internal diameter
COAD Chronic obstructive airway INR International normalized ratio
disease IPPV Intermittent positive pressure
COPA Cuffed oropharyngeal airway ventilation
CPAP Continuous positive airway LA Local anesthesia
pressure LMA Laryngeal mask ventilation
CT Computed tomography min Minute
ECG Electrocardiogram PaCO2 Partial pressure of carbon dioxide
ENT Ear, nose and throat PaO2 Partial pressure of oxygen
ET tube Endotracheal tube PEEP Positive end-expiratory pressure
EtCO2 End-tidal carbondioxide PCT Percutaneous tracheostomy
FG French gauge PDT Percutaneous dilational
FiO2 Fractional inspired oxygen tracheostomy
FOB Fiberoptic bronchoscope PLT Platelets
FRC Functional residual capacity s Seconds
GA General anesthesia SaO2 Arterial oxygen saturation
GWDF Guidewire delating forceps ST Surgical tracheostomy
HDU High dependency unit TIF Tracheoinnominate artery fistula
HME Heat moisture exchanger TLT Translaryngeal tracheostomy
HMEF Heat and moisture exchanging TOF Tracheoesophageal fistula
filter TT Trachestomy tube
ICP Intracranial pressure US Ultrasound
ICU Intensive care unit WOB Work of breathing
 History of Tracheostomy and

1 Evolution of Percutaneous
Tracheostomy

Sushil P Ambesh

INTRODUCTION
Tracheostomy is one of the oldest surgical
procedures described in the literature and refers to
the formation of an opening or ostium into the
anterior wall of trachea or the opening itself,
whereas tracheotomy refers to the procedure to
create an opening into the trachea (Fig. 1.1).1 The
term tracheostomy is used, by convention, for all
these procedures and is considered synonymous
with tracheotomy and is interchangeable. When
done properly, it can save lives; yet the tracheotomy
was not readily accepted by the medical
community. The tracheotomy began as an
emergency procedure, used to create an open airway
for someone struggling for air. For most of its
history, the tracheotomy was performed only as a Fig. 1.1: Tracheostomy (Courtesy: Anatomy Library of
last resort and mortality rates were very high. University of Greifswald, Germany)

HISTORY OF TRACHEOSTOMY
days. He lay in his bed at Mount Vernon, Virginia,
One famous American whose life could have been suffering from a septic sore throat and struggling
saved by a tracheostomy was General George for air (Fig. 1.2). Amongst the several physicians
Washington, the first President of United States of called to Washington’s bedside was personal friend,
America. At the end of the 18th century, however, Dr James Craik. Dr Craik and his colleagues
the procedure was still considered too risky. In diagnosed Washington with an “inflammatory
December 1799 Washington took his daily ride in quinsy”, an inflammation of the throat accompanied
heavy, wintry weather. He developed a sore throat by fever, swelling, and painful swallowing. Three
and a malarial type of fever during the following physicians gathered around him and gave him sage
2 Principles and Practice of Percutaneous Tracheostomy

surgical procedures and a very ancient one.

Tracheostomy has probably existed for more than
4000 years. Rigveda, an ancient sacred Hindu book
referenced the tracheostomy dates back between
3000-2000 BC.4 Egyptian wooden tablets depicts
the surgical procedure of tracheostomy as early as
3000 BC.5 One of the Egyptian tablets from the
beginning of the first dynasty of King Aha was
discovered to have engravings showing a seated
person directing a pointed instrument towards the
throat of another person (Fig. 1.3). Some people
believe it human sacrifice but most experts believe
Fig. 1.2: George Washington lay in his bed at Mount Vernon, that tablet depicts formation of a tracheostomy as
Virginia, suffering from a septic sore throat and struggling human sacrifice was not practiced in ancient Egypt.
for air is attended by his friends and family members The history of surgical access to the airway is
(Courtesy: Library of Congress)
largely one of condemnation. This technique of
slashing the throat to establish emergency airway
tea with vinegar to gargle, but this increased the access in order to save the life was known as “semi
difficulty further and almost choked him. Elisha slaughter.” During the Roman era, tracheostomies
Cullen Dick, youngest amongst three physicians were performed using a large incision but with a
present, proposed a tracheotomy to help relieve warning to not to divide the whole of trachea as it
the obstruction of the throat, but his suggestion could be fatal.6
was considered futile and irresponsible. He was
vetoed by the other two physicians, who preferred
more traditional treatment methods like bleeding
by arteriotomy which was undertaken approxi-
mately four separate times equaling to a total loss
of more than 2500 ml.2 General Washington died
that night. History buffs may recognize this story
as the death of George Washington.3 Modern day
doctors now believe that Washington died from
either a streptococcal infection of the throat, or a
combination of shock from the loss of blood,
asphyxia, and dehydration. One historian has stated Fig. 1.3: A tablet depicting tracheotomy during the king
that “whatever was the direct cause of General Aha Dynasty
Washington’s death, there can be little doubt that
excessive bleeding reduced him to a low state and However, in largely hopeless cases of diphtheria,
very much aggravated his disease.” Had a the opportunities tracheostomy offered for medical
tracheostomy been performed he could have been heroism ensured its place in the surgical
saved. armamentarium. Fabricius wrote in the 17th
Only in the past century has the tracheotomy century, “This operation redounds to the honor of
evolved into a safe and routine medical procedure. the physician and places him on a footing with the
The tracheotomy is actually one of the oldest gods.” Mcclelland had divided various phages of
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