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Tracheostomy: Complete Teaching Guide

1. Definition & Historical Background

• First recorded open tracheostomy: >3,500 years ago (Egyptian dynasty stone slabs)
• Fabricius described the first tracheal cannula in 1617
• Sanctorio Sanctorius: first percutaneous tracheostomy in 1626, using a "ripping needle" to place a silver cannula
• First cuffed tracheostomy tube: 1869, by Trendelenburg
• Modern standardization: early 20th century by American surgeon Chevalier Jackson
• PDT via Seldinger guidewire: Toye & Weinstein (late 1960s)
• Current single-dilator PDT: Pasquale Ciaglia, 1985

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2. Relevant Anatomy

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3. Indications

A. Upper Airway Obstruction

• Head and neck tumors (laryngeal, hypopharyngeal, thyroid)
• Severe maxillofacial trauma
• Angioedema (hereditary or allergic)
• Bilateral vocal cord paralysis
• Foreign body not removable endoscopically
• Epiglottitis with impending obstruction
• Burns/inhalation injury with anticipated swelling

B. Prolonged Mechanical Ventilation

• Most common indication in the ICU
• Considered when ventilation >10-14 days without near-term extubation prospect
• Advantages over prolonged translaryngeal intubation:
  • Reduced sedation requirements (no glottic stimulation)
  • Reduced work of breathing and tube resistance
  • Improved mouth care and oral hygiene
  • Easier bronchopulmonary toilet
  • Facilitates weaning by reducing dead space and resistance
  • Better patient comfort and ability to communicate

C. Neurological Conditions Preventing Safe Extubation

• Severe traumatic brain injury (acute or progressive)
• Spinal cord injury (including patients in halo fixation)
• Prolonged altered mental status
• Severe agitation or delirium
• High aspiration risk with absent gag/cough

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4. Contraindications

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5. Types of Tracheostomy

A. Open (Surgical) Tracheostomy (OST)

• Performed in the operating room (occasionally bedside)
• Direct visualization of tracheal rings
• A vertical incision is made between rings 2-4, then dilated; tube inserted under direct vision
• Neck extended; 2-3 cm incision ~2 cm above sternal notch through platysma and strap muscles
• Thyroid isthmus elevated or divided
• Stoma sutured to skin edges (matured tract in ~4-5 days)
• Preferred when: obesity with inaccessible landmarks, prior anterior neck surgery, severe coagulopathy, abnormal neck anatomy (goitre)

B. Percutaneous Dilatational Tracheostomy (PDT)

• Bedside procedure; standard of care in many ICUs
• Based on Seldinger technique:
  1. ETT withdrawn proximally under bronchoscopic control
  2. Needle inserted between rings 2-3 percutaneously
  3. Guidewire threaded through needle
  4. Serial dilations or single-dilator over guidewire
  5. Tracheostomy tube advanced over dilator/wire
• Bronchoscopic guidance is standard practice
• Cost-effective, no OR wait time needed
• Meta-analysis evidence: PDT has fewer wound infections and bleeding compared to OST; rates of serious complications are similar

C. Emergency Cricothyrotomy

• Not a true tracheostomy, but the emergency airway of last resort
• Incision through cricothyroid membrane (palpated below thyroid notch)
• Transverse incision to lateral borders of thyroid cartilage → rapid dilation → tube insertion
• Must be converted to formal tracheostomy within 24-72 hours (risk of subglottic stenosis)

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6. Tracheostomy Tubes: Types and Components

Basic Components of a Tracheostomy Tube

1. Outer cannula - the main tube inserted into the trachea
2. Inner cannula - removable, can be cleaned or replaced (critical for maintaining airway patency)
3. Obturator - blunt-tipped guide inserted during tube placement; removed immediately after insertion
4. Flange (neck plate) - holds the tube in position at skin surface; secured with tracheostomy ties
5. Cuff (in cuffed tubes) - inflatable balloon that seals the trachea for positive-pressure ventilation

Types of Tubes

Cuff Management

• High-volume, low-pressure cuffs are standard (pressure <25 mmHg / <34 cmH2O)
• High cuff pressures impair mucosal blood flow → pressure necrosis → tracheal stenosis
• Cuff pressure should be checked with a manometer regularly
• Minimal occlusive volume technique: inflate until no air leak, then check pressure

Tube Sizing (Common Sizes)

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7. Timing of Tracheostomy in ICU Patients

• Early tracheostomy (≤7 days or even ≤4 days) vs. late tracheostomy (>10-14 days)
• Most large studies (including the TracMan trial, UK, 900+ patients across 72 ICUs) found:
  • No difference in 30-day or 2-year mortality
  • No difference in pneumonia rates, ICU length of stay, or antibiotic use
  • Over 50% of patients randomized to late tracheostomy did not require it at all (liberated from ventilation before the procedure was needed)
• One randomized trial (medical ICU) found early tracheostomy at 48h vs 14-16 days significantly reduced mortality (32% vs 62%), pneumonia (5% vs 25%), and ICU stay - but this is not consistently replicated
• Practical takeaway: Consider tracheostomy when expected MV duration >14 days. When risk of extubation failure resulting in death >1:1000, proceed with tracheostomy.

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8. The PDT Procedure - Step by Step

1. Preprocedure: Review history, respiratory status, neck anatomy. Review imaging for high-riding innominate artery or aberrant vessels. Ultrasound of neck to mark vessels.
2. Labs: Platelet count, PT/PTT, BUN
3. Team: Proceduralist (bedside), anesthesiologist/airway-trained physician at head of bed, nurse
4. Positioning: Shoulder roll to extend the neck
5. Prep: FiO2 increased to 1.0, sterile field, local anesthetic (1.5% lidocaine with epinephrine) infiltrated
6. Identify landmarks: Thyroid cartilage → cricoid cartilage → 1st, 2nd, 3rd tracheal rings
7. Bronchoscopy: Scope positioned at distal end of ETT; ETT withdrawn to just above ideal entry point under bronchoscopic visualization
8. Needle insertion: 1-1.5 cm horizontal/vertical incision, blunt dissection to tracheal rings, needle inserted between rings 1-2 or 2-3 with bronchoscopic transillumination confirmation
9. Guidewire placement: Through needle into tracheal lumen
10. Dilation: Serial dilators or single-step Ciaglia Blue Rhino dilator advanced over wire
11. Tube insertion: Tracheostomy tube advanced over dilator/wire; dilator removed
12. Confirmation: CO2 detection, capnography (class I AHA recommendation), equal chest rise, bilateral breath sounds, bronchoscopic visualization of tracheal rings
13. Secure: Tracheostomy ties, sutures to neck plate

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9. Complications

Classified by Timing

Key Complications in Detail

Tracheal Stenosis

• Most common late complication
• Mechanism: high cuff pressure → mucosal ischemia → necrosis → loss of cartilage → fibrous narrowing
• Prevention: low-pressure cuffs (keep <25 mmHg), regular cuff pressure monitoring
• Treatment: bronchoscopy + dilation; if severe, tracheal resection and reconstruction

Tracheo-Innominate Artery (TI) Fistula

• Life-threatening (reported mortality >80%)
• Mechanism: tube erodes into innominate artery, especially with tubes placed too low (below ring 3) or in patients with high-riding innominate artery
• Presentation: sentinel bleed (small herald hemorrhage) followed by massive hemorrhage
• Emergency management: overinflate cuff, digital pressure through stoma, immediate OR for vessel repair or ligation

Tracheoesophageal Fistula

• Mechanism: erosion of posterior tracheal wall (membranous portion) into esophagus, often by overinflated cuff or low-pressure high-volume cuff against rigid NG tube
• Features: food/fluid coming through tracheostomy, recurrent aspiration pneumonia, air in stomach on X-ray
• Treatment: surgical repair

Tube Obstruction

• Most common complication in the ED (30% of respiratory ED visits)
• Causes: dried secretions (most common), blood, aspirated material, granulation tissue, cuff herniation
• Management: remove and clean inner cannula first; if not improved, attempt suctioning; if still obstructed, change outer cannula

Tube Dislodgement

• Occurs most often in early post-op period (before tract maturation ~4-5 days)
• Emergency: if <72h post-op, do NOT blindly attempt re-insertion; cover stoma, bag-mask via mouth, call for surgical backup
• If tract mature: can re-insert with obturator using neck extended, then confirm with capnography

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10. Tracheostomy Tube Change

• Tracheostomy tube of same size (and one size smaller as backup)
• Cuff syringe, suction, oxygen source, Ambu bag
• Lubricating jelly, forceps
• Capnography if available

1. Preoxygenate with 100% O2
2. Suction trachea and oropharynx
3. Deflate cuff (if cuffed)
4. Remove old tube while patient breathes normally
5. Insert new tube with obturator in place at 90° angle, sweep downward
6. Remove obturator, insert inner cannula, inflate cuff
7. Confirm placement: capnography, chest auscultation, direct visualization

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11. Post-Operative & Ongoing Care

Routine Care

• Suctioning: As needed (not on a fixed schedule); use appropriate catheter size (no larger than 1/2 the inner diameter of the tube); suction during withdrawal not insertion
• Inner cannula cleaning: Every 8 hours (or replace if disposable); prevents obstruction from dried secretions
• Stoma care: Clean with normal saline/water, change tracheostomy dressings daily; keep skin dry to prevent breakdown
• Humidification: Bypass of upper airway humidification requires external humidification (heated humidifier or HME filter) to prevent mucus plugging
• Cuff pressure monitoring: Check every 8-12 hours; maintain 20-25 mmHg (25-30 cmH2O)
• Tracheostomy ties/holder: Change daily; always keep one finger width between ties and neck

Nursing Assessment

• Assess breathing pattern, RR, SpO2, work of breathing
• Listen for upper airway sounds (stridor = possible obstruction or dislodged tube)
• Observe stoma site for infection, granulation tissue, skin breakdown
• Assess secretion character (amount, color, consistency) - purulent secretions suggest infection
• Always keep a spare tube (same size + one size smaller) and obturator at bedside

Communication

• Cuffed tube prevents speech (air does not pass through cords)
• Strategies: fenestrated tube (cuff deflated), speaking valve (Passy-Muir valve), writing, communication boards, electronic devices
• Passy-Muir Valve (PMV): One-way valve placed on tracheostomy hub; allows inspiration through tube but forces expiration up through cords → enables voice; requires cuff to be fully deflated when using PMV

Swallowing Assessment

• Aspiration risk is elevated with tracheostomy (altered laryngeal elevation, sensory changes)
• Bedside swallowing assessment, modified barium swallow, or FEES (flexible endoscopic evaluation of swallowing) recommended before oral feeding

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12. Decannulation (Weaning from Tracheostomy)

1. Underlying cause resolved
2. Adequate spontaneous ventilation (weaned from mechanical ventilation)
3. Adequate cough and airway protection
4. Secretion load manageable
5. Patent upper airway (confirmed endoscopically)
6. No significant aspiration

1. Downsize the tube progressively
2. Trial of capping (placing a cap over the tube opening) - patient breathes entirely around the tube
3. Deflate cuff during waking hours, then 24 hours
4. If patient tolerates capping for 24 hours without distress → decannulate
5. Tracheal buttons (Montgomery button): maintain stoma patency during weaning in patients who need periodic suctioning but do not need mechanical ventilation; can be retained permanently if decannulation fails

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13. Special Situations

COVID-19 and Tracheostomy

• PDT is an aerosol-generating procedure requiring airborne + droplet precautions
• Evidence supports waiting 10-14 days of mechanical ventilation before tracheostomy in COVID-19 patients (associated with lower duration of MV and ICU stay without increased mortality)
• Tracheostomy on ECMO is feasible; complications higher (mainly bleeding) but no difference between PDT and OST

Pediatric Tracheostomy

• Softer cartilage, smaller anatomy - more technically demanding
• Highest risk period is the first weeks (accidental dislodgement before tract maturation)
• Staying sutures placed around tracheal rings to facilitate emergency re-insertion
• More common long-term complications: tracheal growth disturbance, suprastomal collapse

Obese Patients

• PDT may be done safely but requires appropriate (extended-length) kit
• Surgical approach may be preferred for class III obesity
• Ultrasound assessment of neck anatomy essential before PDT

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14. Emergency Management of Tracheostomy Complications

Blocked Tube (Obstruction)

1. Remove and inspect inner cannula → clean/replace
2. Pass suction catheter → clear secretions
3. If still obstructed → change the tube
4. If unable to re-intubate stoma → oral intubation

Dislodged Tube

• Immature tract (<5 days): Do not blindly re-insert. Apply O2 to stoma, ventilate via mouth/nose, urgent surgical assistance
• Mature tract (>5 days): Replace with obturator in place; extend neck; confirm placement; if resistance, downsize the tube

Hemorrhage

• Minor: Usually from granulation tissue; direct pressure, silver nitrate cautery
• Massive (sentinel bleed scenario): Suspect TI fistula. Overinflate cuff; apply digital pressure through stoma anteriorly; immediate OR

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Summary Table: Key Facts at a Glance

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