Critical Procedures

Percutaneous Tracheostomy & Cricothyroidotomy

Includes pre-procedure assessment, bronchoscopic guidance, stepwise dilation, troubleshooting, post-procedure care, and when to favor surgical approaches.

Tracheostomy • Emergency airway • ComplicationsReading time · 27mWord count · 3,439

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Exam mapping & scope

This chapter covers indications, contraindications, patient selection, pre-procedure evaluation, technique, troubleshooting, complications, and post-procedure care for percutaneous dilational tracheostomy (PDT/PT) and cricothyroidotomy. Emphasis is placed on bedside decision-making in the ICU, device options and steps, guidance modalities (bronchoscopy and ultrasound), anticoagulation/antiplatelet management, special populations (obesity, high ventilatory support, coagulopathy, ECMO/COVID), and emergency “can’t intubate, can’t oxygenate” (CICO) rescue with needle, surgical, or percutaneous cricothyroidotomy.

Focus this round

Patient selection
Bleeding control
Emergency rescue

High-yield pearls

PT vs. ST: Overall complication rates are similar. PT has lower wound infection rates, shorter procedure times, and lower costs. Bleeding risk is generally comparable.
Guidance: Bronchoscopic guidance improves first-pass success and reduces complications. Ultrasound adds value for anatomy/vascular mapping and may reduce major bleeding.
Puncture site: Midline between the 1st–2nd or 2nd–3rd tracheal rings under bronchoscopy; keep the endotracheal tube (ETT) just below the cricoid during puncture.
Coagulopathy: Aim for INR <1.5 and platelets >50 × 10⁹/L (transfuse if needed). If able, hold clopidogrel ≥5 days; PT can still be done with antiplatelet/anticoagulants in select settings with informed consent.
Ventilator settings: PT is feasible even with higher PEEP; coordinate ETT retraction and minimize disconnections to preserve PEEP.
Obesity: Not a contraindication in expert hands; anticipate a deeper trachea and consider extra-long tracheostomy tubes (XLT).
Early complications: Subcutaneous emphysema (~1.4%), pneumothorax (~0.8%), bleeding, malposition. Manage with bronchoscopy, tube exchange over a guide, and hemostasis.
Late complications: Tracheal stenosis (clinically significant 3–12%), tracheomalacia, tracheo-innominate fistula (TIF <1%—a surgical emergency).

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