State of the art: percutaneous tracheostomy in the intensive care unit

Percutaneous tracheostomy is a commonly performed procedure for patients in the intensive care unit (ICU) and offers many benefits, including decreasing ICU length of stay and need for sedation while improving patient comfort, effective communication, and airway clearance. However, there is no consensus on the optimal timing of tracheostomy in ICU patients. Ultrasound (US) and bronchoscopy are useful adjunct tools to optimize procedural performance. US can be used pre-procedurally to identify vascular structures and to select the optimal puncture site, intra-procedurally to assist with accurate placement of the introducer needle, and post-procedurally to evaluate for a pneumothorax. Bronchoscopy provides real-time visual guidance from within the tracheal lumen and can reduce complications, such as paratracheal puncture and injury to the posterior tracheal wall. A step-by-step detailed procedural guide, including preparation and procedural technique, is provided with a team-based approach. Technical aspects, such as recommended equipment and selection of appropriate tracheostomy tube type and size, are discussed. Certain procedural considerations to minimize the risk of complications should be given in circumstances of patient obesity, coagulopathy, or neurologic illness. Herein, we provide a practical state of the art review of percutaneous tracheostomy in ICU patients. Specifically, we will address pre-procedural preparation, procedural technique, and post-tracheostomy management.