# Tracheotomy: Indications, Technique, and Management

## Introduction

**Tracheotomy** is one of the oldest and most commonly performed surgical procedures in otolaryngology. It involves creating an opening in the anterior tracheal wall to establish a direct airway. Understanding the indications, techniques (open and percutaneous), perioperative management, and complications is fundamental to otolaryngologic training.

## Terminology

**Tracheotomy**: the surgical procedure of creating an opening in the trachea. **Tracheostomy**: the resultant stoma (opening); commonly used interchangeably with tracheotomy. **Cricothyrotomy**: emergency surgical airway through the cricothyroid membrane (not a tracheotomy).

## Indications

### Airway Obstruction
Upper airway obstruction (tumor, bilateral vocal fold paralysis, angioedema, trauma). Failed intubation or cannot-intubate/cannot-ventilate scenario.

### Prolonged Mechanical Ventilation
Expected need for ventilatory support >10-14 days. Facilitates weaning, reduces dead space, improves patient comfort. Reduces laryngeal injury from prolonged translaryngeal intubation.

### Pulmonary Toilet
Inability to clear secretions (neuromuscular disease, stroke, spinal cord injury). Facilitates suctioning and bronchial hygiene.

### Other Indications
Adjunct for major head and neck surgery (mandibulotomy, skull base surgery). Obstructive sleep apnea refractory to other treatments (rare). Subglottic or tracheal stenosis management.

## Anatomy

**Thyroid cartilage**: superior landmark. **Cricoid cartilage**: palpable below the thyroid cartilage. **Cricothyroid membrane**: between the thyroid and cricoid cartilages. **Tracheal rings**: C-shaped cartilaginous rings; tracheotomy typically placed between rings **2-3 or 3-4**. **Thyroid isthmus**: crosses the trachea at approximately rings 2-3; may need to be divided or retracted. **Innominate (brachiocephalic) artery**: crosses the trachea at the level of the sternal notch; at risk with low tracheotomy. **Recurrent laryngeal nerves**: run in the tracheoesophageal grooves bilaterally.

![Cross-sectional anatomy of the anterior neck at the level of the trachea showing key structures for tracheotomy](/images/tracheotomy-anatomy.jpg)

## Open Surgical Tracheotomy Technique

### Setup
**Position**: supine with shoulder roll for neck extension (unless contraindicated by cervical spine injury). General anesthesia with endotracheal tube or local anesthesia with sedation. Mark landmarks: cricoid, sternal notch, midline.

### Procedure
**Horizontal skin incision** midway between cricoid and sternal notch (or vertical in emergencies). Dissect through subcutaneous tissue and platysma. Separate the **strap muscles** in the midline (linea alba cervicalis). Identify and manage the **thyroid isthmus** (divide or retract). Identify tracheal rings; confirm midline position. Enter the trachea between rings 2-3 or 3-4 with a **horizontal incision or Bjork flap** (inferiorly based tracheal flap sutured to skin). Withdraw the endotracheal tube under direct visualization. Insert the **tracheostomy tube** and confirm placement with ventilation and end-tidal CO2. Secure the tube with sutures and tracheostomy ties.

### Bjork Flap
Inferiorly based flap of the anterior tracheal wall sutured to the skin. Facilitates tube reinsertion if accidental decannulation occurs. Controversial: some surgeons prefer a simple window or horizontal incision.

## Percutaneous Dilational Tracheotomy (PDT)

### Technique
Performed at the **bedside in the ICU** using bronchoscopic guidance. Seldinger technique: needle puncture of trachea, guidewire insertion, serial dilation, tube placement. Common systems: Ciaglia (single dilator), Griggs (forceps-based).

### Advantages
Cost-effective (avoids OR time), quick, can be performed bedside. Comparable safety and complication rates to open technique in selected patients.

### Contraindications to PDT
Pediatric patients, difficult neck anatomy (short, obese neck), previous neck surgery. Coagulopathy, high ventilatory requirements (high PEEP), Palpable innominate artery or aberrant vessels, Emergency airway situations.

## Tracheostomy Tube Selection

| Tube Feature | Options | Indication |
|-------------|---------|------------|
| Cuff | Cuffed vs. uncuffed | Cuffed: mechanical ventilation; Uncuffed: long-term, speaking |
| Inner cannula | Present vs. absent | Present: reduces obstruction risk, easy cleaning |
| Fenestration | Fenestrated vs. non-fenestrated | Fenestrated: allows phonation, upper airway airflow |
| Flange | Standard vs. adjustable | Adjustable: deep/unusual neck anatomy |
| Material | Silicone, PVC, metal (Jackson) | Metal: long-term; PVC/silicone: standard |

**Size**: outer diameter should be approximately 2/3 to 3/4 of the tracheal lumen. **Cuffed vs. uncuffed**: cuffed for ventilated patients; uncuffed for long-term use and speaking. **Inner cannula**: removable for cleaning; reduces tube obstruction risk. **Fenestrated**: allows phonation and airflow through the upper airway. **Adjustable flange**: for patients with deep or unusual neck anatomy.

## Postoperative Management

### Immediate Care (0-7 Days)
**First tube change**: typically at postoperative day 5-7 (allows tract maturation). Humidified air/oxygen to prevent mucus crusting, Regular suctioning with appropriate catheter size. Keep **spare tracheostomy tube and obturator** at bedside at all times. **Stay sutures** in the trachea to facilitate reinsertion if accidental decannulation in the first week.

### Ongoing Care
Inner cannula cleaning or replacement every 4-8 hours. Tracheostomy site care: clean and dry; change dressing daily. Monitor for granulation tissue, stomal infection, tube malposition. **Speaking valve (Passy-Muir)**: redirects airflow through the larynx; requires cuff deflation and adequate upper airway patency. Swallowing evaluation: tracheostomy can impair swallowing mechanics.

### Decannulation
Patient must demonstrate: adequate airway, ability to manage secretions, no ongoing need for ventilation. **Capping trial**: cap the tube for 24-48 hours while monitoring oxygen saturation and respiratory effort. Downsizing the tube before decannulation is common. After removal, the stoma typically closes within 48-72 hours (persistent tracheocutaneous fistula may require surgical closure).

![Algorithm for tracheostomy management from placement through decannulation](/images/tracheostomy-management-algorithm.jpg)

## Complications

### Early (Days)
**Hemorrhage**: usually minor; innominate artery erosion is catastrophic (tracheo-innominate fistula). **Pneumothorax/pneumomediastinum**: from paratracheal dissection. **Tube displacement/false passage**: most dangerous early complication; reinsert over suction catheter or use stay sutures. **Subcutaneous emphysema**.

### Late (Weeks to Months)
**Tracheo-innominate fistula**: massive hemorrhage; sentinel bleed may precede; hyperinflate cuff to tamponade, apply digital pressure through the stoma against the sternum; emergent surgical intervention required. **Tracheal stenosis**: from cuff pressure necrosis or stomal granulation; occurs at the stoma, cuff site, or tube tip. **Tracheoesophageal fistula**: from posterior tracheal wall erosion. **Tracheocutaneous fistula**: persistent stoma after decannulation. **Granulation tissue**: at the stoma or within the tracheal lumen.

![Bronchoscopic image of tracheal granulation tissue at a tracheostomy site](/images/tracheal-granulation-bronchoscopy.jpg)

## Key Clinical Pearls

The **first tracheostomy tube change** should not be performed before postoperative day 5-7 to allow tract maturation. Always have a **spare tube, obturator, and suction** at the bedside. **Tracheo-innominate fistula** typically occurs 1-3 weeks postoperatively; any significant bleeding from a tracheostomy is this diagnosis until proven otherwise. Keep the tracheotomy at rings 2-4; too high risks subglottic stenosis, too low risks innominate artery injury. Cuff pressures should be maintained at **<25 cmH2O** to prevent tracheal mucosal ischemia and stenosis. Accidental decannulation in the first week is a surgical emergency — use stay sutures and a Bjork flap to reduce risk.

## References

1. Cheung NH, Napolitano LM. Tracheostomy: epidemiology, indications, timing, technique, and outcomes. *Respir Care*. 2014;59(6):895-919.
2. Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. *Otolaryngol Head Neck Surg*. 2013;148(1):6-20.
3. Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilational tracheostomy: a new simple bedside procedure. *Chest*. 1985;87(6):715-719.
4. Epstein SK. Late complications of tracheostomy. *Respir Care*. 2005;50(4):542-549.