Tracheostomy

Definition

A tracheostomy is a surgical procedure that creates an opening (stoma) in the anterior (front) cervical trachea, through which a tube is inserted to establish a direct airway. The terms "tracheostomy" and "tracheotomy" are used interchangeably by convention. It is the most common surgical procedure performed in critically ill patients requiring prolonged mechanical ventilation. - Sabiston Textbook of Surgery, p. 960

Indications

Indications fall into three broad categories:

Category	Examples
Upper airway obstruction	Angioedema, upper airway tumors, significant maxillofacial trauma, difficult airway
Prolonged mechanical ventilation	ICU patients requiring ventilation beyond 7-14 days
Neurologic conditions	Brain injury (acute or progressive), spinal cord injury, severe agitation, prolonged altered mental status

Sabiston Textbook of Surgery, p. 960

Benefits Over Prolonged Translaryngeal (Oral) Intubation

For patients needing ongoing ventilation, tracheostomy provides:

Reduced sedation requirements (no glottic stimulation)
Reduced tube resistance and work of breathing
Reduced airway dead space
Better mouth care and oral hygiene
Easier bronchial toilet (tracheal suctioning) once weaned
Scott-Brown's Otorhinolaryngology, Vol 1, p. 405

Types of Tracheostomy

1. Surgical (Open) Tracheostomy

Performed in the operating room
Involves direct incision and dissection to expose the trachea
Preferred in: obesity (large neck), coagulopathy/bleeding disorders, anatomical variance (previous surgery, goiter)

2. Percutaneous Dilatational Tracheostomy (PDT)

First described by Ciaglia et al. in 1985; now widely used
Performed at the bedside in the ICU - this is the standard in most institutions
Uses a Seldinger-based technique: needle insertion into trachea > guidewire passed > sequential dilation > tracheostomy tube placed over wire
Done under bronchoscopic guidance or ultrasound guidance
Compared to surgical tracheostomy: shows less wound infection and similar or lower complication rates
Periprocedural mortality: less than 0.2% in randomized studies
More cost-effective than surgical tracheostomy in ICU patients
Sabiston Textbook of Surgery, p. 960; Scott-Brown's Otorhinolaryngology, Vol 1, p. 405

Timing

Early (within 4-7 days) vs. Late (after 10-14 days): remains controversial
Most large trials (including the TracMan trial of 900+ patients across 72 ICUs in the UK) show no mortality difference between early and late tracheostomy
Notably: over 50% of patients randomized to late tracheostomy did not end up needing one, as they were liberated from mechanical ventilation first
Some studies do show shorter ICU stays and fewer ventilator days with early tracheostomy
Sabiston Textbook of Surgery, p. 960

Contraindications (mostly relative)

Recent anterior neck surgery (within 7 days)
Hemodynamic instability
High ventilator settings (FiO2 >50%, PEEP >10 cmH2O)
Elevated intracranial pressure
Significant bleeding risk / coagulopathy
Local infection or malignancy at proposed site
Predicted early mortality

Complications

Immediate / Periprocedural

Bleeding (from anterior jugular veins or thyroid isthmus)
Pneumothorax
Tube misplacement / false passage
Loss of airway

Early (within days-weeks)

Stomal site infection
Tube obstruction
Inadvertent tube dislodgement (high-risk emergency if within first 7 days)
Subcutaneous emphysema

Late (weeks to months)

Tracheal stenosis - the most significant late complication; subclinical stenosis found in up to 40% of patients; symptomatic stenosis in ~6%
Tracheomalacia
Tracheo-innominate artery fistula (rare but life-threatening)
Persistent stoma / failure to close
Sabiston Textbook of Surgery, p. 961

Safety Measures

Use of bronchoscopic guidance or semi-open technique during PDT
Pre-procedure ultrasound to identify neck vasculature, thyroid anatomy, and guide needle placement (especially useful in obese patients)
Dedicated multidisciplinary tracheostomy teams have been shown to reduce time to decannulation, hospital length of stay, and adverse events

Special Considerations

COVID-19: Tracheostomy is an aerosol-generating procedure; airborne and droplet precautions are required. Data suggest performing after 10-14 days of ventilation is safer.
ECMO patients: Tracheostomy can be safely performed at the bedside; bleeding complications are higher overall, but percutaneous and open techniques show similar complication rates.
Pediatric patients: Nasotracheal intubation is preferred over tracheostomy in acute laryngeal infections (e.g., croup, epiglottitis) when feasible. Equipment for emergency tracheostomy must always be immediately available.
Decannulation: When no longer needed, the tube is removed and the stoma closes spontaneously. In pediatric patients, further procedures (for granulation tissue, suprastomal collapse, or subglottic stenosis) may be needed before successful decannulation.

This is a shared conversation. Sign in to Orris to start your own chat.