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For the single dilator systems, activate the coating by immersing the distal end of the dilator in sterile water or saline. Slide the dilator up to the safety ridge on the guiding catheter, then with concurrent bronchoscopic visualization, advance the dilator assembly using the Seldinger technique over the guidewire into the trachea. After passage to the appropriate depth (marked on the dilator), it is withdrawn and advanced several times to dilate the tract (Figure 8). For multiple dilator systems, serial dilation is performed with incrementally larger dilators (Figures 7 and 8).

The lubricated tracheotomy tube (loaded on a dilator/guiding catheter unit) is then advanced over the guidewire into the trachea (Figure 9). The guidewire and dilator are then removed, leaving the tracheotomy tube in place. The cuff of the tracheotomy tube is inflated and the inner cannula inserted. The ventilator tubing or an Ambu bag device is disconnected from the ETT and attached to the PDT tube (Figure 10). The translaryngeal ETT is not removed until correct intratracheal placement of the tracheotomy tube has been confirmed visually by bronchoscopy (Figure 10).

The incision is typically just large enough to accommodate the tracheotomy tube and does not require closure. Nonabsorbable suture is used to secure the tracheotomy cuff to the skin and securing tapes are placed to hold the PDT tube in place usually over a dry sterile gauze dressing (Figure 11).

A chest x-ray is ordered to confirm tracheotomy tube position and evaluate for pneumothorax or pneumomediastinum. Elevate the head of the patient's bed 30 to 40 degrees immediately following the procedure and suction any bloody secretions. The tracheal tapes and cuff sutures should not be removed until the first tracheotomy tube change. Ideally, the first tube change should not be attempted until the tract has matured, which requires at least 7 to 10 days. If accidental decannulation occurs within the first 7 days of PDT, an oral ETT should be placed instead of attempting reinsertion of the tracheotomy tube through the stoma. Dislodgement of a tracheotomy tube that has been in place 2 weeks or longer can often be managed simply by replacing the tube through the mature tract. Humidification and frequent tracheal suctioning is recommended to prevent inspissation of secretions, which can result in mucous plugging and tracheotomy tube obstruction.

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