Percutaneous Dilational Tracheostomy

CPT 31600
Approach Percutaneous
Add-on / Variant CPTs
  • 31500 — Change of tracheostomy tube (if existing stoma)
Preoperative Diagnosis:

Prolonged mechanical ventilation / [anticipated prolonged intubation / failed extubation / need for long-term airway management / pulmonary toilet]

Postoperative Diagnosis:

Same

Procedure Performed:

Percutaneous dilational tracheostomy with bronchoscopic guidance

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident / PA / second physician for bronchoscopy]

Anesthesia:

Moderate sedation: [propofol / midazolam + fentanyl], neuromuscular blockade: [cisatracurium / vecuronium], local: [X] mL 1% lidocaine with epinephrine

Indications:

The patient is a [age]-year-old [male/female] requiring tracheostomy for [prolonged mechanical ventilation / failed extubation / need for long-term airway management / pulmonary toilet]. The decision was made to perform percutaneous dilational tracheostomy at the bedside given [stable hemodynamics / ICU transport risk]. Pre-procedure CT neck [or landmark assessment] was reviewed. The risks, benefits, and alternatives were discussed with the patient's [family / surrogate], and informed consent was obtained.

Findings:

The anterior trachea was well visualized bronchoscopically at the [2nd-3rd / 3rd-4th] tracheal ring interspace. The trachea was midline without significant deviation. The puncture needle was visualized entering the tracheal lumen in the midline under bronchoscopic guidance. A [8.0 / 8.5] mm [Shiley / Portex] tracheostomy tube was successfully placed without complication. Bronchoscopy confirmed correct intratracheal position with the tip [2–3 cm] above the carina. Bilateral breath sounds and end-tidal CO2 waveform confirmed proper position.

Description of Procedure:

The patient was already mechanically ventilated via endotracheal tube. Sedation was deepened and neuromuscular blockade was administered. The FiO2 was increased to 100%. The patient was positioned supine with the neck in extension using a shoulder roll.

The anterior neck was prepped with ChloraPrep and draped in sterile fashion. The cricoid cartilage and tracheal rings were identified by palpation. The planned puncture site at the [2nd-3rd] tracheal ring interspace was infiltrated with [X] mL of 1% lidocaine with epinephrine.

A flexible bronchoscope was passed through the ETT to the level of the carina. The ETT was withdrawn under bronchoscopic visualization until the cuff was just below the cords, providing adequate tracheal exposure at the planned puncture site.

A [1.5 cm] horizontal skin incision was made at the planned site with blunt dissection to the anterior tracheal wall. A [14-gauge] introducer needle was advanced through the tracheal membrane under direct bronchoscopic visualization in the midline, confirmed by transillumination and by direct visualization of the needle entering the tracheal lumen. A guidewire was advanced through the needle and its intratracheal position was confirmed bronchoscopically.

Sequential dilation was performed using the [Ciaglia Blue Rhino / Griggs forceps] technique. The stoma was dilated over the guidewire to the appropriate size. A [8.0 / 8.5] mm [Shiley] tracheostomy tube loaded on its introducer was advanced over the guidewire into the trachea. The guidewire and introducer were removed. The cuff was inflated.

The bronchoscope was passed through the tracheostomy tube to confirm intratracheal position with the tip [2–3 cm] above the carina. The ETT was removed under bronchoscopic visualization. Bilateral breath sounds were confirmed, end-tidal CO2 waveform was present, and SpO2 remained stable. The tracheostomy tube was secured with a tracheostomy collar and [0-silk / Dacron tie].

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal (less than 10 mL)

Drains:

[8.0 / 8.5] mm [Shiley] cuffed tracheostomy tube, connected to mechanical ventilation

Disposition:

The patient was maintained on mechanical ventilation via tracheostomy. Post-procedure CXR was obtained to confirm tube position. Cuff pressure was checked and maintained at 20–25 cmH2O. First tracheostomy tube change planned for post-operative day [5–7].

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Prolonged mechanical ventilation, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Percutaneous dilational tracheostomy with bronchoscopic guidance
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Sedation: ***, neuromuscular blockade: ***, local: *** mL 1% lidocaine with epinephrine

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX requiring tracheostomy for ***. Consent obtained from ***.

FINDINGS: Anterior trachea visualized at ***-*** ring interspace. Needle confirmed midline by bronchoscopy. *** mm tracheostomy tube placed. Tip *** cm above carina on bronchoscopy. ETCO2 present, bilateral breath sounds equal.

PROCEDURE:
Patient supine, neck extended with shoulder roll. FiO2 100%. Sedation deepened, NMB administered. Neck prepped and draped in sterile fashion.

Landmarks identified. *** mL 1% lido with epi infiltrated at ***-*** ring interspace. Bronchoscope passed, ETT withdrawn to just below cords.

*** cm skin incision, blunt dissection to anterior tracheal wall. 14g needle advanced under bronchoscopic visualization in midline. Needle confirmed in tracheal lumen. Guidewire advanced, position confirmed bronchoscopically.

Sequential dilation via *** technique. *** mm Shiley tracheostomy tube advanced over wire. Introducer and wire removed. Cuff inflated. Bronchoscopy confirmed tip *** cm above carina. ETT removed. ETCO2 present, bilateral breath sounds equal, SpO2 stable. Tube secured with collar and tie.

COMPLICATIONS: None
EBL: Minimal
DISPOSITION: Continued on mechanical ventilation via tracheostomy. Post-procedure CXR ordered.

Signed: .ME, .MYDEGREE
.TODAY
Variants

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.
Billing Tips
  • Bill 31600 for planned/elective tracheostomy (5.42 wRVU, 0-day global). Use for percutaneous dilational tracheostomy (PDT) and open surgical tracheostomy performed as a scheduled procedure in a stable patient.
  • Bill 31500 for emergency tracheostomy (2.93 wRVU, 0-day global) when performed urgently for airway obstruction or failed intubation. Document the emergent clinical circumstances clearly.
  • Bronchoscopic guidance during percutaneous tracheostomy (31622, 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. Subsequent tracheostomy tube changes after discharge use 31502.
  • If performed in the ICU by a surgeon under critical care supervision, document the procedure separately from the critical care note. Critical care time (99291/99292) and the procedure (31600) are both billable on the same day if the procedure time is excluded from critical care time.