Percutaneous Dilational Tracheostomy
Percutaneous dilational tracheostomy with bronchoscopic guidance
[X] days of mechanical ventilation with [failure to wean / failed extubation / anticipated prolonged ventilation / need for pulmonary toilet] requiring tracheostomy for long-term airway management.
Informed consent was obtained from the [patient / patient's surrogate] after discussion of risks, benefits, and alternatives.
[***, MD/DO]
[Resident/PA name] [and [name], MD/DO, performing bronchoscopy]
Deep sedation with [propofol / midazolam and fentanyl], neuromuscular blockade with [cisatracurium / vecuronium], and local infiltration with [X] mL of 1% lidocaine with epinephrine
The trachea was midline without significant deviation. The needle was visualized bronchoscopically entering the tracheal lumen in the midline at the [2nd-3rd / 3rd-4th] tracheal ring interspace. Bronchoscopy through the tracheostomy tube showed the tip [2–3] cm above the carina. End-tidal CO2 waveform and bilateral breath sounds were present, and SpO2 remained stable.
A time-out was completed confirming the patient and procedure. Coagulation studies and platelet count were reviewed and acceptable. Neck anatomy was reviewed by [CT / landmark examination], and bedside placement was chosen given [stable hemodynamics / ICU transport risk].
The patient was mechanically ventilated via endotracheal tube. Sedation was deepened, neuromuscular blockade was administered, and FiO2 was increased to 100%. The patient was positioned supine with the neck extended over a shoulder roll.
The anterior neck was prepped with chlorhexidine and draped in sterile fashion. The cricoid cartilage and tracheal rings were identified by palpation, and the planned puncture site was infiltrated with [X] mL of 1% lidocaine with epinephrine.
A flexible bronchoscope was passed through the endotracheal tube, and the tube was withdrawn under bronchoscopic visualization until the cuff was just below the vocal cords, exposing the planned puncture site.
A [1.5] cm horizontal skin incision was made, and blunt dissection was carried down to the anterior tracheal wall. A [14-gauge] introducer needle was advanced between the tracheal rings into the lumen under bronchoscopic visualization, with transillumination confirming the midline position. A guidewire was advanced through the needle, and its intratracheal position was confirmed bronchoscopically.
The stoma was dilated over the guidewire using the [Ciaglia Blue Rhino / Griggs forceps] technique. The tracheostomy tube, loaded on its introducer, was advanced over the guidewire into the trachea. The guidewire and introducer were removed, and the cuff was inflated.
Bronchoscopy through the tracheostomy tube confirmed intratracheal position, and the endotracheal tube was removed. The tracheostomy tube flange was secured with [0-silk sutures / a Dacron tie].
[8.0 / 8.5] mm cuffed [Shiley / Portex] tracheostomy tube
Minimal (less than 10 mL)
None
None
The patient will continue mechanical ventilation via the tracheostomy. A post-procedure chest radiograph has been ordered to confirm tube position. Cuff pressure will be maintained at 20–25 cmH2O. Sedation will be [weaned / continued], and routine tracheostomy care will be provided. The first tracheostomy tube change is planned for post-procedure day [5–7].
Epic SmartPhrase Version
PROCEDURE: Percutaneous dilational tracheostomy with bronchoscopic guidance
INDICATION: *** days of mechanical ventilation with *** requiring tracheostomy for long-term airway management.
CONSENT: Informed consent obtained from the [patient / surrogate] after discussion of risks, benefits, and alternatives.
PERFORMED BY: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Deep sedation: ***, neuromuscular blockade: ***, local: *** mL 1% lidocaine with epinephrine
FINDINGS: Trachea midline. Needle visualized bronchoscopically entering lumen in midline at ***-*** ring interspace. Tip *** cm above carina on bronchoscopy. ETCO2 present, bilateral breath sounds equal, SpO2 stable.
PROCEDURE DETAILS:
Time-out completed. Coags and platelets reviewed, acceptable. Neck anatomy reviewed by ***. Bedside placement given ***.
Sedation deepened, NMB administered, FiO2 100%. Supine, neck extended with shoulder roll. Neck prepped with chlorhexidine and draped in sterile fashion. Landmarks identified. *** mL 1% lidocaine with epinephrine infiltrated. Bronchoscope passed, ETT withdrawn to cuff just below cords.
*** cm skin incision, blunt dissection to anterior tracheal wall. 14g needle advanced between rings under bronchoscopic visualization, midline confirmed by transillumination. Guidewire advanced, position confirmed bronchoscopically.
Stoma dilated over wire via *** technique. Tracheostomy tube on introducer advanced over wire. Introducer and wire removed. Cuff inflated. Position confirmed bronchoscopically through trach. ETT removed. Flange secured with ***.
DEVICE PLACED: *** mm cuffed *** tracheostomy tube
EBL: Minimal
SPECIMENS: None
COMPLICATIONS: None
POST-PROCEDURE PLAN: Mechanical ventilation via tracheostomy. Post-procedure CXR ordered. Cuff pressure 20–25 cmH2O. Sedation ***. Routine trach care. First trach change POD ***.
Signed: .ME, .MYDEGREE
.TODAYVariants
Converted to Open Surgical Tracheostomy
Given [bleeding / difficult anatomy / inability to identify tracheal rings percutaneously / failed dilation / patient instability], the decision was made to proceed with open surgical tracheostomy in the operating room rather than continuing with the percutaneous approach. The procedure was terminated and the patient was transported to the OR for formal tracheostomy under controlled conditions.
Tracheostomy Tube Change
The patient's existing [size] mm tracheostomy (placed on [date]) was changed at the bedside. The tracheostomy site was mature. The old tube was deflated and removed. A [size] mm [Shiley / Portex] tracheostomy tube was inserted through the established stoma without difficulty. The cuff was inflated. Tube position was confirmed by ETCO2, breath sounds, and [bronchoscopy if performed]. Cuff pressure was set at 20–25 cmH2O. Tube secured with collar and tie.
Charting Tips
- Document bronchoscopic confirmation of needle placement in the midline tracheal lumen. This is the defining safety step of PDT and distinguishes it from blind percutaneous placement. Without this documentation, the procedure appears unsafe.
- Record the specific tracheal ring interspace used. Placement at the 1st ring or above the cricoid risks subglottic stenosis. Placement below the 4th ring risks innominate artery erosion. Document that the site was appropriate.
- Document post-procedure tube position bronchoscopically (cm above carina) and by CXR. Note cuff pressure checked at 20–25 cmH2O, as over-inflation leads to tracheomalacia and under-inflation risks aspiration.
- When the percutaneous approach is unsuitable (unclear landmarks, emergent airway, or conversion for bleeding or failed dilation), refer to the open surgical tracheostomy template.
Documentation & Reimbursement Considerations
- Primary service: Report Percutaneous Dilational Tracheostomy as the primary service when it is the definitive operation performed.
- Planned tracheostomy (5.42 wRVU, 0-day global) is reported for percutaneous dilational tracheostomy (PDT) and open surgical tracheostomy performed as a scheduled procedure in a stable patient.
- Bronchoscopic guidance during percutaneous tracheostomy (2.47 wRVU) can be billed separately when a bronchoscopist provides independent guidance. Document that two physicians were present and that the bronchoscopy was a separate service from the tracheostomy itself.
- 0-day global period: tracheostomy care, tube changes, and downsizing within the same admission are not separately billable by the operating surgeon.
- If performed in the ICU by a surgeon under critical care supervision, document the procedure separately from the critical care note. Critical care time and the tracheostomy are both billable on the same day if the procedure time is excluded from critical care time.