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