Collaborate with your peers and learn from the experts, who share their experience and knowledge to assist you in learning about percutaneous tracheostomy. Visit the Vista website for more information and to register for an upcoming session of our “Innovations in Bedside Procedures” course.
For complete prescribing information, including indications for use, warnings, precautions, adverse events, and procedural instructions, refer to the Instructions for Use (IFU), which can be found on the Blue Rhino® G2-Multi Percutaneous Tracheostomy Introducer page.
6. Generously lubricate the surface of the appropriately sized loading dilator and load the tracheostomy tube onto the dilator. Ensure that the tracheostomy tube’s tip fits snugly on the dilator. (Fig. 2) Ensure that the balloon is completely deflated. Thoroughly lubricate the tracheostomy tube assembly.
1. Palpate landmark structures (thyroid notch, cricoid cartilage) to ascertain the proper location for tracheostomy tube placement. Access and, ultimately, tube placement is ideally made at the level between the first and second tracheal cartilages or between the second and third tracheal cartilages whenever feasible. (Fig. 3)
4. Deflate the endotracheal tube cuff and withdraw to an appropriate distance above the insertion site, yet still within the trachea. Re-inflate the cuff once the proper position of the endotracheal tube has been reached.
6. With the needle tip positioned in the trachea, local anesthesia may be injected (if necessary).
7. When free flow of air is obtained, with no impalement of the endotracheal tube, remove the inner needle of the introducer needle assembly and advance the outer FEP sheath several millimeters. NOTE: If using an introducer needle without a sheath, proceed to step 9.
10. Remove the FEP sheath or introducer needle while maintaining wire guide position within the tracheal lumen. (Fig. 9)
12. Remove the dilator while maintaining wire guide position.
13. Activate the hydrophilic coating by immersing the distal end of the Blue Rhino G2-Multi dilator in sterile water or saline.
15. Begin to dilate the tracheal access site by advancing the guiding catheter and Blue Rhino G2-Multi dilator into the trachea. To properly align the dilator on the wire guide/guiding catheter assembly, position the proximal end of the dilator at the single positioning mark on the guiding catheter. This will ensure that the distal tip of the dilator is properly positioned at the safety ridge on the guiding catheter to prevent possible trauma to the posterior tracheal wall during introduction. While maintaining the visual reference points and positioning relationships of the wire guide, guiding catheter and dilator, advance them as a unit to the skin level mark on the Blue Rhino G2-Multi dilator. (Fig. 11) NOTE: Proper positioning and alignment may help minimize complications (e.g., stenosis).
17. Remove the Blue Rhino G2-Multi dilator, leaving the wire guide/guiding catheter assembly in position. Respiratory air leak through the tracheostomy stoma should be noted to confirm intratracheal location of the wire guide and guiding catheter.
18. Advance the tracheostomy tube (loaded on the dilator) over the wire guide/guiding catheter assembly to the safety ridge of the guiding catheter, then advance wire guide, guiding catheter, loading dilator, and tracheostomy tube as a unit into trachea. (Fig. 12) NOTE: The assembly should be directed perpendicular to the axis of the trachea during insertion for uniform dilation between tracheal cartilages. Once the tracheostomy tube is within the tracheal lumen, the assembly may be directed caudad. NOTE: Proper positioning and alignment may help minimize complications (e.g., stenosis).
20. Inflate the tracheostomy tube balloon cuff. Connect the tracheostomy tube to the ventilator. Confirm position of the tracheostomy tube via standard methods (e.g., capnography, breath sounds, etc.).
21. Deflate and remove the endotracheal tube.
22. Perform suction to determine if any significant bleeding or possible obstruction exists that has not been noted to this point.
23. If necessary, one suture may be taken at the bottom of the initial incision.
Cabrini L, Landoni G, Greco M, et al. Single dilator vs. guide wire dilating forceps tracheostomy: a meta-analysis of randomised trials. Acta Anaesthesiol Scand. 2014;58(2):135–142.
Cabrini L, Pintaudi M, Winterton D, et al. Choice of the appropriate tracheostomy technique. In: Servillo G, Pelosi P, eds. Percutaneous Tracheostomy in Critically Ill Patients. New York, NY: Springer; 2016:67–78.
Cobean R, Beals M, Moss C, et al. Percutaneous dilatational tracheostomy: a safe, cost-effective bedside procedure. Arch Surg. 1996;131(3):265–271.
Delaney A, Bagshaw S, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care. 2006;10(2):R55.
Freeman BD, Isabella K, Cobb JP, et al. A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients. Crit Care Med. 2001;29(5):926–930.
Kornblith LZ, Burlew CC, Moore EE, et al. One thousand bedside percutaneous tracheostomies in the surgical intensive care unit: time to change the gold standard. J Am Coll Surg. 2011;212(2):163–170.
Marra A, Danzi M, Vargas D, et al. Tracheostomy in intensive care unit: the need of European guidelines. In: Servillo G, Pelosi P, eds. Percutaneous Tracheostomy in Critically Ill Patients. New York, NY: Springer; 2016:155–159.
Mehta C, Mehta Y. Percutaneous tracheostomy. Ann Card Anaesth. 2017;20(Suppl 1):S19–S25.
Newhouse E, Ondik MP, Carr M, et al. Who is performing percutaneous tracheotomies? Practice patterns of surgeons in the USA. Eur Arch Otorhinolaryngol. 2011;268(3):415–418.
Rashid AO, Islam S. Percutaneous tracheostomy: a comprehensive review. J Thorac Dis. 2017;9 (Suppl 10):S1128–S1138.
Vargas M, Servillo G, Arditi E, et al. Tracheostomy in intensive care unit: a national survey in Italy. Minerva Anestesiol. 2013;79(2):156–164.