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N. A. Watson et al.
3.3 Types ofLaryngoscopes
andPharyngoscopes
There are a number of different laryngoscopes and pharyngoscopes in use worldwide but the ones the authors have
found the most useful are: the Lindholm (standard and
extended) useful for supraglottic and glottic lesions (Fig.3.8),
Dedo laryngoscope for access to the anterior commissure
and Dohlman/ Weerda distending operating diverticuloscope
(Fig.3.9) for cricopharyngeal myotomy, in the management
of pharyngeal pouches.
Fig. 3.6 Traditional suspension laryngoscope and gallows
Fig. 3.8 Storz Lindholm laryngoscope
Fig. 3.7 Storz anterior commissure laryngoscope
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be used with extension at the atlanto-occipital joint and exion of the neck on the chest. This is generally achieved with
a head ring and elevation of the head of the table, as required,
to provide optimal glottic exposure. Glottic pressure may be
applied by the surgeon, assistant or straps if the view of the
larynx is not optimal once the suspension has been applied
[3]. MRI studies of different head and neck positions during
microlaryngoscopy have conrmed the Boyce-Jackson
exion- extension position to be optimal for viewing the larynx at microlaryngoscopy compared with extensionextension and neutral positions of the head and neck [4].
This position has also been shown to reduce the pressure on
the soft tissues and mucosa signicantly, protects the spine
and minimises the risk of peri-and postoperative complications [5]. Note some surgeons still prefer to use the extensionextension position where the head is placed directly on the
operative table and is extended on the body and also on the
neck (Fig.3.11) [6].
3.4.3 Examination
Fig. 3.9 Storz Weerda Diverticuloscope
3.4 Shared Principles ofPharyngoscopy
andLaryngoscopy
3.4.1 Instruments
Pharyngoscope/laryngoscope (small/medium/large bore,
anterior commissure), light carrier suction device and tubing,
lubrication jelly, 0-, 30-, and 70-degree rigid endoscopes,
light lead, anti-fog solution, 1:10000 adrenaline in gallipot
and 1×1 or 3cm neuro patties, Mayo/suspension table, suspension arm, stack with computer screen and camera for
image capture, microscope, and theatre layout as depicted in
the schematic (Fig.3.10).
3.4.2 Position ofthePatient
In pharyngoscopy, the patient is placed in the supine position, with a shoulder bolster under the shoulders, (but no
head ring) to allow the oesophagus to be in line with the
upper pharynx. This position also allows oesophagoscopy, if
required.
In laryngoscopy, the aim is to obtain the best possible
view of the glottis. The Boyce-Jackson position continues to
A silicone gumshield is placed to protect the top teeth, in a
dentate patient. If edentulous or laser is being used, a wet
gauze is placed over the upper gum to protect from injury.
The pharyngoscope/laryngoscope of choice is held in the
one hand, the ngers of the other hand help protect the
lips±teeth and tongue as the scope hand guides the beak of
the instrument towards the oropharynx.
For pharyngoscopy, it is important to examine the oropharynx as the pharyngoscope is guided towards to hypopharynx. Digital palpation of the oropharynx and base of
tongue should also be performed as this can elicit non-visible
submucosal masses.
In laryngoscopy, the scope is inserted in the right side of
the oral cavity, sweeping the tongue to the left and advanced
until the ET tube (if present) and epiglottis are viewed.
Depending on the type of scope used, the beak is passed
either anterior or posterior to the epiglottis to view the larynx. When a Lindholm laryngoscope is used, the beak of the
scope advances anterior to the epiglottis into the vallecula;
hence, the epiglottis is within your view. However, with most
other scopes, the beak is placed entirely posterior to the epiglottis, into the supraglottis.
3.4.4 One-Handed Technique
Hold the endoscope in the non-dominant hand and the instruments in the dominant hand.
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Theatre layout for microlaryngoscopy
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Fig. 3.10 Schematic of an
example theatre layout
N. A. Watson et al.
Anaesthetic machine
Microscope
3.4.5 Two-Handed Technique
withSuspension Microlaryngoscopy
Once the laryngoscope is in the right place and a satisfactory
view of the glottis is obtained, the laryngoscope is placed in
suspension with the help of a suspension arm and a Mayo table
or suspension arm of choice. A microscope is moved in front of
the laryngoscope at a distance of 20–25cm allowing a direct
line of sight of the larynx, freeing both hands for the intended
microlaryngoscopy procedure (Fig.3.12). Images/recording of
the larynx/glottis can be taken either with a rigid laryngoscope
attached to a high-denition (HD) camera before and after any
procedure or with a microscope- attached HD camera.
Table
Surgeon
Scrub nurse
AV stack
Screen
3.4.6 Laser Modications
Safety modications are necessary for the use of a laser during microlaryngoscopy. These include the use of a laser-safe
cuffed endotracheal tube, placing of wet gauze over the
exposed areas of the face and neck of the patient, a jug of
normal saline available to extinguish any re that may occur,
maintaining the patient’s oxygen saturations within normal
limits by pre-oxygenating the patient, so that the oxygen
administered can be reduced to <40% [7] during laser use
(preferably 21%) [8], using wet neuro patties during the procedure and the wearing of laser safety goggles and laser safe
masks by staff during the procedure.
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3.4.7 Set-Up forEndoscopic Laryngoscopy
Although suspension microlaryngosocopy with a microscope can offer good views of the larynx and free both hands
for instrumentation, the use of a rigid laryngoscope attached
to an HD camera can offer unparalleled high-quality images
of the larynx.
The use of a 0-, 30-, and 70-degree Hopkin’s rigid endoscopes allows the visualisation of all but the most hidden
anatomical features. The use of image enhanced laryngoscopy (see below) provides additional information.
On occasions, visualisation of the larynx, especially the
anterior part of the vocal folds and anterior commissure, in
particular, is difcult. The use of a 30-degree endoscope can
greatly improve visualisation and hence instrumentation.
Angled instruments may be required to reach the most anterior anatomical structures of the larynx in this situation:
70-degree scopes are particularly useful in staging and visualising neoplasms.
Once the suspension set-up is complete and the scope
stable, instruments may be passed down the scope enabling
both diagnosis and interventions using either a one- or twohanded technique (Fig.3.13).
Fig. 3.11 Pharyngoscopy/laryngoscopy basic instrument set-up
Fig. 3.12 Schematic of
endoscopic approach to
suspension laryngoscopy
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Fig. 3.13 Schematic of microscopic approach to suspension
laryngoscopy
3.5 Image-Enhanced Flexible
Laryngoscopy
Imaged-enhanced laryngoscopy provides high-contrast
images of lesions of the larynx and pharynx by means of
optical and digital technologies, allowing contrast enhancement of the mucosal surfaces and blood vessels. These technologies give further information by which the clinician can
help differentiate between malignant and inammatory
lesions by demonstrating the angiogenesis associated with
early cancers. Examples include narrow-band imaging
(NBI), i-SCAN, exible spectral imaging colour enhancement (FICE), and Storz Professional Image Enhancement
System (SPIES). NBI uses optically modied white light
(blue and green light) to enhance the contrast between the
mucosal epithelium and submucosal vessels, whereas
I-SCAN, FICE, and SPIES also enhance the contrast but create this effect by digitally manipulating the image with postimage processing.
The most widely used within ENT to date is NBI which has
been shown to improve sensitivity and specicity of assessment of laryngeal lesions, helps with the diagnosis of precancerous and cancerous lesions, and facilitates more precise
assessment of the status of surgical margins of early- stage and
N. A. Watson et al.
locally advanced laryngeal cancers managed with endoscopic
laser resection and cordectomy. Changes in the microvascular
architecture of the mucosa are classied according to Arens
ELS classication [9]. NBI can also be useful in characterising
hypertrophic lesions: laryngeal papillomatosis [10].
3.6 Anaesthetic Considerations
Operating in the pharynx, larynx, and trachea poses the
anaesthetist numerous challenges as there is a shared airway,
which can be compromised during the pre-, intra-, or postoperative period [11]. Pre-operative planning is key with the
chosen setting for anaesthesia being in the operating theatre
on the operating table in order to avoid any delay in achieving the wider team in rescuing an airway or choosing a surgical airway. Also, this setting, when using a tubeless eld
technique, which is growing in popularity, limits the patient’s
stimulation, movement in transfer, and delay in the surgeon
commencing the procedure.
The “Laryngoscore” has been externally validated to be
used for predicting good or difcult laryngeal exposure for
laryngological procedures [6]. The Laryngoscore developed
by Piazza etal rates 11 parameters: interincisors gap, thyromental distance, maxillary dental status, trismus, mandibular
prognathism, macroglossia, micrognathia, degree of neck
exion-extension, previous open-neck surgery and/or radiotherapy, Mallampati modied score, and body mass index,
providing a score between 0 and 17 [12]. The original Piazza
score of 6 and above predicted a difcult laryngeal examination in 40% of patients.
Timing and medical optimisation of the patient as necessary is of the essence in any laryngoscopy procedure. In
acute airway situations, optimisation with intravenous steroids, nebulised adrenaline anti-sialogogues, heliox, or highow oxygen with nasal cannulae via OptiFlow™ may
provide crucial stabilisation of the airway prior to securing
the airway with intubation prior to the procedure. If available, airway assessment with cross-sectional imaging and, if
possible, a virtual reconstruction of the airway±3D printed
airway should be shared with the anaesthetic, nursing, and
surgical teams. The gold standard pre-operative assessment
of the airway is exible naso-laryngoscopy, recorded and
stored electronically and made available for the multidisciplinary theatre team to view prior to general anaesthetic.
This can also be performed in the anaesthetic room if necessary. However, it is important to note that even though anatomically we can plan to predict the outcome, we will not
know how the airway will react to general anaesthesia physiologically. An ultrasound machine can be used to preoperatively mark the cricothyroid membrane for marking
rescue airway strategies. An experienced team should preferably be available to manage the airway and a 3-point airway
plan made for each patient.
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Topical anaesthesia of the upper and lower airway mucosa
with local anaesthetic is used prior to intubation and
decreases stimulation of the larynx during intubation and the
intended procedure. A maximum of 8mg/kg of topical lidocaine should provide a safe and effective topical anaesthetic
effect. Some anaesthetists choose to use a 4% nebulised lidocaine and or delivery via a malleable atomiser: Madgic
device (Teleex®). Total intravenous anaesthesia (TIVA)
infusion using propofol and low-dose remifentanil has grown
in popularity and inhalational induction is now less popular
in microlaryngoscopy and pharyngoscopy. TIVA is a prerequisite for a tubeless eld.
3.6.1 Tubeless Ventilation
Tubeless ventilation provides the surgeon with a better eld
of vision and less risk of re during a laser procedure than
with an endotracheal tube. However, there are disadvantages
of tubeless ventilation; prolonged ventilation is not possible
(except in the case of using super-imposed high-frequency
jet ventilation), there is a small risk of barotrauma, CO2
retention, and this method might not be suitable in obese
patients nor those with poor lung function.
A tubeless eld is generally preferred by the surgeon and
the two methods commonly used are Transnasal Humidied
Rapid-Insufation Ventilatory Exchange (THRIVE) or jet
ventilation. THRIVE is a physiological mechanism for oxygenating and ventilating patients who are under general
anaesthesia and who have diminished or absent respiratory
effort. The ventilation for THRIVE occurs with a noninvasive nasal cannula providing oxygen at 70–90 L/min,
which loops around the soft palate, and exits through the
mouth. Humidication and warming generate a positive airway pressure even if the mouth is open, which in turn reduces
upper airway collapse and distal airway atelectasis. However,
full CO2 clearance cannot be achieved and, thus, CO2 accumulates, limiting the operating time to an average of
30–40min.
THRIVE patients are pre-oxygenated positioned at 40°
head-up with OptiFlow™ nasal cannula at a rate of 20L/
min, and then total intravenous anaesthesia commences and
the ow increases to 40–60L/min over 1min. The mouth is
encouraged to be closed during this period. Once loss of consciousness has been achieved, OptiFlow™ is increased to
70 L/min. The anaesthetist maintains jaw-thrust, the head
end of the table is lowered to 0–20°, and two facemask
breaths are given during a temporary suspension of
OptiFlow™ in order to check the ease of ventilation and
adequacy of relaxation. OptiFlow™ is then resumed and the
surgeon takes over the airway to commence pharyngolaryngoscopy with gradual pressure suspension microlaryngoscopy. The vocal cords are then sprayed with local
anaesthetic (e.g. 10% Xylocaine).
Once the procedure is complete, the laryngoscope is
removed and the surgeon must maintain a jaw thrust and
either the surgeon or anaesthetist inserts a laryngeal mask
airway or i-gel. Ventilation is then conrmed, and the patient
may be transferred on continuous oxygen to recovery.
Spontaneous ventilation re-commences, and then the patient
awakes. Contraindications to THRIVE include morbid obesity, total airway obstruction, and suspected or known skull
base fracture.
Sometimes jet ventilation is preferred. Single- frequency
jet ventilation can be either manual or automated highfrequency jet ventilation. Barotrauma is the main complication causing morbidity and mortality [11]. Caution must also
be taken to avoid gas trapping by ensuring sufcient outow.
The manual jet can be provided by a Sanders-type injector and
the automated devices are the Mistral or Monsoon. Jet ventilation can be delivered via supraglottic, transglottic, or transtracheal pathways. Supraglottic jet ventilation will provide a true
tubeless eld but air trapping is particularly at risk especially
in those with small diameter stenoses. Transglottic causes
minimal vocal cord displacement but still may hinder surgical
access to the posterior larynx and subglottis. The transtracheal
route can be delivered via a cricothyroid cannula, for example
Ravussin; however, there is concern that this may be associated with complications during jet ventilation [11].
Single-frequency jet ventilation is limited to less than
30–40min due to the CO2 retention and subsequent metabolic acidosis. The superimposed high-frequency
(TwinStream™) jet ventilation system, however, allows continuous monitoring of pressures, end-tidal CO2 as well as
FiO2; hence, patients can be anaesthetised for hours in an
open system (Figs.3.14 and 3.15). It is suitable for use in
obese patients and those with pulmonary diseases. This latter
type of ventilation delivers larger tidal volume than singlefrequency ventilation techniques.
Fig. 3.14 Superimposed high-frequency (Twinstream™) jet ventilation set-up with suspension laryngoscopy
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Fig. 3.15 Superimposed
high-frequency
(Twinstream™) jet ventilation
machine
N. A. Watson et al.
3.6.2 Intubated Ventilation
This is the use of conventional tracheal intubation. A narrow
bore microlaryngeal tube (MLT) tube, exometallic (reinforced) or laser-safe/resistant tube is used to deliver conventional assisted ventilation in some patients undergoing
laryngeal surgery.
3.7 Summary
Examination of the larynx and pharynx can be performed as
either an ofce procedure or theatre procedure under local or
general anaesthetic, respectively. There has been much
development with image technology in the ofce setting over
the last 40years with the advent and continued development
of HD imaging allowing superb visualisation of the larynx
and pharynx and the relatively more recent introduction of
image enhanced technology, such as NBI.For patients undergoing operative procedures under general anaesthesia, surgical planning is of paramount importance with any operation
involving the airway. Pre-optimisation and consideration of
the most appropriate anaesthetic, whether to use tubed or
tubeless ventilation, should be a joint multidisciplinary decision when planning the operation. The choice of the operative scopes used will depend on the task at hand and
commonly used operative scopes include the Lindholm,
Dedo, anterior commissure laryngoscopes, and Dohlman
diverticuloscope.
References
1. St Clair T, Negus V.Diseases of the nose and throat. Cassell and Co
Ltd. 1948. p.406.
2. Lewis R, Scott-Brown W. Diseases of the ear, nose and throat.
London: Butterworth’s; 1952.
3. Hamilton N, Elmiyeh B, Sandhu G.Patient position for microlaryngoscopy: a trainee survey. Clin Otolaryngol. 2010;35(3):254–5.
4. Tong B, Fang R, Smith BL.Study of the head and neck position in
microlaryngoscopy using magnetic resonance imaging. Eur Arch
Otorhinolaryngol. 2013;270(1):243–7.
5. Friedrich G, Gugatschka M. Inuence of head positioning
on the forces occurring during microlaryngoscopy. Eur Arch
Otorhinolaryngol. 2009;266(7):999–1003.
6. Tirelli G, Gatto A, Fortunati A, Marzolino R, Giudici F, Boscolo
Nata F. Predicting laryngeal exposure in microlaryngoscopy: external validation of the laryngoscore. Laryngoscope.
2019;129(6):1438–43.
7. Li S, Chen L, Tan F. Laryngeal surgery using a CO2 laser: is a
polyvinylchloride endotracheal tube safe? Am J Otolaryngol.
2012;33(6):714–7.
8. Spruce L.Back to basics: laser safety. AORN J. 2019;110(5):524–32.
9. Davaris N, Lux A, Esmaeili N, Illanes A, Boese A, Friebe M,
etal. Evaluation of vascular patterns using contact endoscopy and
narrow- band imaging (CE-NBI) for the diagnosis of vocal fold
malignancy. Cancers. 2020;12(1):248.
10. Ochsner MC, Klein AM.The utility of narrow band imaging in the
treatment of laryngeal papillomatosis in awake patients. J Voice.
2015;29(3):349–51.
11. Pearson K, McGuire B.Anaesthesia for laryngo-tracheal surgery,
including tubeless eld techniques. BJA Educ. 2017;17(7):242–8.
12. Piazza C, Mangili S, Bon FD, Paderno A, Grazioli P, Barbieri D,
et al. Preoperative clinical predictors of difcult laryngeal exposure for microlaryngoscopy: the laryngoscore. Laryngoscope.
2014;124(11):2561–7.
Part II
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Airway Surgery
Percutaneous Tracheostomy andOpen
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Standard Surgical Tracheostomy
KennethMuscat andSanjaiSood
4
4.1 Introduction
Tracheostomy is recognised as one of the oldest surgical procedures, with references to the creation of a surgical airway
in the neck dating back to 3600 BC and pictures found in
Egyptian art. The term tracheostomy refers to the creation of
a communication between the trachea and the overlying skin
of the neck. This procedure can be done in an elective or an
emergency setting, and the stoma formed can be either temporary or permanent. Chevalier Jackson established the principles of the open standard surgical tracheostomy operation
in the beginning of the twentieth century, and these have
remained largely unchanged [1]. There is some debate about
the optimal incision to use in the open surgical technique for
adult patients undergoing tracheostomy. The options range
from simple horizontal or vertical tracheotomy incisions,
removing various sections in various shapes of the anterior
tracheal rings to form a tracheal window, or the creation of a
Bjork ap to be xed to the skin of the neck [2]. All of these
techniques have their proponents, and there is currently no
evidence to support one technique as superior.
With the expansion of intensive care units and wider use
of long-term ventilation, the request for tracheostomy procedures has increased exponentially. The need for this procedure to be performed readily in certain critical care patients,
together with logistic and cost-related issues, led to the
development of the bedside percutaneous dilational tracheostomy technique. Inspired by the Seldinger technique used
for cannulation of veins and arteries, Ciaglia etal. published
the basics of this technique in 1985 [3]. His method was
based on serial dilations of a tract over a guide-wire, and it
K. Muscat (*)
Department of Otorhinolaryngology-Head and Neck Surgery,
Mater Dei Hospital, Msida, Malta
S. Sood
Department of Otorhinolaryngology–Head and Neck Surgery,
Bradford Teaching Hospitals NHS Trust, Bradford, UK
e-mail: sanjai.sood@bthft.nhs.uk
gained popularity because it was reliable, reproducible, and
relatively safe when compared with previously reported
attempts in the literature. Subsequently, further variations of
the percutaneous dilational tracheostomy method have been
reported. Schachner et al. reported the Rapitrach method,
which consisted of a dilating forceps with a metal conus
inserted in the airway over a guide-wire through the neck [4].
Fantoni and Ripamonti described the translaryngeal tracheostomy method, which interestingly used a retrograde technique, passing a specically designed cannula through the
mouth over a previously placed guide-wire [5]. The medical
engineering industry further developed and rened equipment materials in order to specically facilitate a singlestage technique for the dilation of the tracheostomy tract. For
example the Ciaglia Blue Rhino technique, described by
Byhahn etal., resulted in a quicker procedure with less intraoperative bleeding and less risk of posterior tracheal wall
injury [6].
Development of the percutaneous dilational tracheostomy
technique was a signicant advancement in minimally invasive bedside procedures, and it denitely offers certain
advantages. When compared with the standard open
approach, the total time taken to do the procedure and the
overall total costs are less [7]. There are also fewer logistic
issues, and various papers in the literature have reported
equal or reduced complication rates when compared with the
standard technique [7]. That being said, the percutaneous
dilational tracheostomy technique is typically used only in
patients with optimal neck anatomy and in cases where a
rigid checklist of patient and equipment factors is met, in
order for it to be performed safely. When such factors are not
met, the gold standard is still the classic open surgical
tracheostomy.
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_4
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K. Muscat and S. Sood
4.2 Preoperative Checklist,
Considerations, andAnaesthesia
In the elective setting, one must ensure that adequate
informed consent, covering indications for the procedure,
options available to the patient, and potential complications,
has been taken before performing any type of tracheostomy.
It is also important to discuss the possibility that a tracheostomy may end up being permanent. According to the clinical
circumstances, both patients and relatives should be allowed
to understand the decision-making process and should be
adequately prepared for the postoperative challenges, including routine tracheostomy care and communication difculty
due to lack of vocalisation.
Good communication should be present between the
intensive care and surgical teams involved in tracheostomy
decision-making. It is in fact good practice to check whether
a surgeon capable of performing an open surgical approach
is available before starting a percutaneous dilational tracheostomy, in case of an unexpected complication (such as
bleeding), which may dictate the need to explore the site
surgically.
It is imperative to check all relevant preoperative investigations, especially coagulation studies, as any bleeding diathesis, particularly if uncontrolled, is a contraindication for
using the percutaneous dilational tracheostomy technique. In
patients with a coagulopathy, bleeding factors should be
optimised as much as possible before starting an open surgical approach.
For a patient to be suitable for percutaneous tracheostomy, the intensive care physician should consider him or her
to be easily re-intubatable through the per-oral route in case
of accidental extubation. In case of doubt, it is safer to proceed with a standard open approach. The same approach
should be taken in the presence of laryngeal tumour, which
may present distortion of anatomy, a difcult airway, seeding
of tumour, or increased potential bleeding.
It is essential to examine and assess the clinical anatomy
of the neck to evaluate suitability for percutaneous tracheostomy; the patient should have adequate ability to hyperextend the neck, and the distance between the cricoid cartilage
and suprasternal notch should be at least 3–4cm [8]. Making
sure the patient does not have an unstable cervical spine is a
must, as this would preclude neck extension. Evidence of
soft tissue infections at the anterior neck entry site or haematoma formation are also contraindications for a percutaneous
tracheostomy. In addition, one should be able to clearly palpate and identify the thyroid and cricoid cartilages. Such
anatomical landmarks are difcult to identify in obese
patients, making them less suitable for the percutaneous
technique. These patients also have large amounts of soft tissue between the anterior tracheal wall and the skin, produc-
ing a long tracheostomy tract that remains collapsible for
weeks with the percutaneous technique, making a change of
tracheostomy tubes difcult and risky. Therefore, one should
consider the open surgical approach if the planned tract is
long or if the tracheostomy is needed for long-term use. A
number of other anatomical variations, such as large thyroid
goitres, suprasternal masses, or abnormal pulsations in the
lower central neck, should also be evaluated. These are all
relative contraindications for the percutaneous technique.
Additional radiological investigations, including a bedside
neck ultrasound scan, should be requested to investigate any
suspected abnormalities, to help facilitate the decision
regarding the type of procedure and the setting in which it
should be performed. A good practice in the intensive care
setting is to check the endotracheal tube positioning on the
latest chest x-ray to exclude any gross deviations from the
midline.
The classic open technique should be used in children
because of the difculty of palpating the smaller trachea and
the softer cartilaginous rings, which are more susceptible to
iatrogenic trauma. The smaller diameter of the child’s trachea also increases the risk of damage to the posterior tracheal wall. Hyperextension should also be avoided in
children because of an increased risk of damage to the thoracic inlet vessels.
Preoperatively, it is essential to review the selection of
tracheostomy tubes and type of percutaneous kits available
and decide which one to use according to the indication and
the experience or preference of the operator. A tube of a size
above and a size below the one chosen should be readily
available. Occasionally, special tubes with extra length or
reinforcement may be needed, and a tracheostomy procedure
should not be started until these are available [9]. Although
there has been debate about the need for procedural adjuncts,
such as sonography and bronchoscopy (rigid or exible),
during the percutaneous technique, most large teaching units
consider these to be routine elements for performing this
procedure. Sonography excludes problems in the path of the
guide-wire and helps to direct the insertion trocar in the trachea. Bronchoscopy is the gold standard to ascertain that the
needle is in the midline and not placed laterally. Our advice
is that if such equipment is present in the intensive care setting, it should be used routinely to minimise the complication rate. Some clinicians would consider changing to an
open approach if these are unavailable.
Ideally, both types of tracheostomy techniques should
be done under general anaesthesia, with a dedicated anaesthetist responsible for administration of the sedative, muscle relaxant, and analgesic medication. If general
anaesthesia is unavailable or contraindicated, an open classic surgical tracheostomy should be performed using local
anaesthetic.
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