Tracheostomy (elective and emergency)

Surgical approach (open surgical tracheostomy)

• Position: supine, shoulder roll, neck extension (may be limited in C-spine instability/obesity/neck mass)
• Incision: horizontal skin crease (often 1–2 cm above sternal notch) or vertical midline in emergency
• Dissection: midline separation of strap muscles; identify thyroid isthmus (retract superiorly/inferiorly or divide/ligate)
• Expose anterior trachea (usually between 2nd–4th tracheal rings); avoid cricoid and 1st ring (risk subglottic stenosis)
• Create tracheal opening: window excision, Björk flap (inferiorly based), or vertical slit; control bleeding
• Insert tracheostomy tube (cuffed in most ICU/ventilated patients); confirm position and ventilation; secure with tapes/sutures
• Optional: stay sutures placed on tracheal rings (aid re-insertion if displaced early)

Surgical approach (percutaneous dilatational tracheostomy, PDT)

• Usually ICU bedside; neck extension; ultrasound may identify vessels/thyroid; bronchoscopy often used to guide and reduce posterior wall injury
• Needle puncture trachea (typically between 2nd–3rd or 3rd–4th rings) → guidewire (Seldinger) → serial/one-step dilatation (e.g. Ciaglia Blue Rhino) → tube insertion
• Confirm ventilation and end-tidal CO2; secure tube; CXR selectively (if concern for pneumothorax/malposition)

Anaesthetic management (elective tracheostomy in theatre)

• Type of anaesthesia: usually GA; occasionally LA + sedation in high-risk airway/awake approach (requires experienced team, careful titration, full airway rescue plan)
• Airway: typically oral ETT in situ initially; withdraw ETT under direct laryngoscopy/bronchoscopy so cuff sits just below cords and above tracheostomy site; avoid accidental extubation
• Alternative airway: reinforced ETT may help; in shared-airway cases consider microlaryngoscopy tube; avoid SGA as definitive airway for open tracheostomy unless specific plan and immediate conversion
• Duration: typically 30–60 min (open); longer if complex anatomy/bleeding/neck surgery
• Analgesia: moderate pain; multimodal (paracetamol ± NSAID if appropriate, small opioid doses); local infiltration by surgeon helpful
• Key intra-op risks: loss of airway during ETT manipulation; bleeding; airway fire if diathermy with high FiO2; surgical emphysema/pneumothorax; aspiration
• Ventilation strategy: reduce FiO2 as low as safely possible during tracheal entry/diathermy; communicate before tracheal incision; consider apnoea during tracheal opening if requested
• Confirmation after tube insertion: ETCO2, bilateral chest movement/auscultation, airway pressures, ability to pass suction catheter; consider bronchoscopy if doubt

Anaesthetic management (PDT in ICU)

• Type of anaesthesia: deep sedation + analgesia + neuromuscular blockade (to prevent coughing/movement and loss of airway); ensure haemodynamic support available
• Airway: existing oral ETT; withdraw to just below cords under laryngoscopy/bronchoscopy; ensure cuff not at puncture site; secure ETT firmly
• Monitoring: full AAGBI monitoring + capnography; consider arterial line; suction and difficult airway equipment immediately available
• Ventilation: pre-oxygenate; reduce FiO2 during tracheal puncture/diathermy if used; anticipate transient loss of PEEP and derecruitment
• Analgesia: fentanyl/alfentanil/remifentanil commonly; local infiltration at puncture site

Anaesthetic management (emergency tracheostomy / front-of-neck access context)

• Emergency tracheostomy is rarely first-line in CICO; recommended immediate technique is scalpel cricothyroidotomy (then convert to tracheostomy later if needed)
• If emergency tracheostomy is required (e.g. obstructing laryngeal tumour where cricothyroidotomy impossible/unsafe): call ENT, prepare for bleeding and distorted anatomy; oxygenation strategy paramount
• Anaesthesia: often local anaesthetic with minimal sedation (maintain spontaneous ventilation) or GA with inhalational/IV induction only if confident of oxygenation and rescue options
• Airway plan: awake fibreoptic intubation may be preferable if feasible; if not, awake tracheostomy under LA; have suction, vasoconstrictor, blood products, and difficult airway trolley

Definition and types

• Tracheostomy: surgical creation of a stoma into the trachea with insertion of a tube to maintain airway/ventilation
• Types: open surgical tracheostomy (theatre), percutaneous dilatational tracheostomy (ICU), emergency tracheostomy (rare), temporary vs long-term
• Differentiate from cricothyroidotomy: access via cricothyroid membrane; preferred emergency front-of-neck access in CICO

Indications

• Airway obstruction: upper airway tumour, trauma, oedema, bilateral vocal cord palsy, severe OSA with anatomical obstruction (selected cases)
• Facilitate prolonged ventilation/weaning: reduce sedation, improve comfort, facilitate tracheal toilet, enable step-down care
• Airway protection: poor cough/swallow (neuromuscular disease, bulbar dysfunction), recurrent aspiration (selected cases)
• Secretion management: copious secretions, impaired clearance
• Access for head and neck surgery / shared airway (occasionally pre-emptive)

Contraindications / relative contraindications (especially PDT)

• Unfavourable anatomy: inability to extend neck, morbid obesity with impalpable landmarks, large goitre, high-riding innominate artery, previous neck surgery/radiotherapy, tracheal deviation
• Coagulopathy/anticoagulation: correct where possible; weigh bleeding risk vs urgency (open may be preferred in some cases)
• High ventilatory requirements: very high PEEP/FiO2 (risk derecruitment); consider delaying or performing with advanced support
• Local infection/burns at site; unstable cervical spine; paediatrics (PDT generally avoided)

Pre-op assessment and preparation (elective)

• Airway assessment: cause of airway compromise, stridor, positional symptoms, previous radiotherapy/surgery; review imaging (CT neck/chest) if available
• Bleeding risk: anticoagulants/antiplatelets, platelet count, coagulation; group and save/crossmatch if high risk
• Respiratory status: baseline gas exchange, secretion load, aspiration risk; plan post-op destination (ICU/HDU/ward with tracheostomy-trained staff)
• Equipment: appropriate tracheostomy tubes (sizes, cuffed/uncuffed, adjustable flange, inner cannula), suction, capnography, fibreoptic scope; difficult airway trolley; emergency tracheostomy box at bedside post-op
• Team brief: shared airway, timing of ETT withdrawal, FiO2 reduction, plan for loss of airway/bleeding; assign roles

Intra-op key points (shared airway)

• ETT position management: withdraw only when surgeon ready; maintain control of tube; confirm ventilation after any movement
• Avoid endobronchial intubation after manipulation; watch airway pressures and unilateral chest movement
• Airway fire prevention: minimise FiO2, avoid N2O, communicate before diathermy enters airway; saline available
• When trachea opened: expect leak and loss of ventilation; consider pausing ventilation if requested; protect against aspiration of blood
• After tracheostomy tube insertion: confirm ETCO2; secure tube; ensure cuff inflated before positive pressure ventilation; document tube type/size/length

Post-op care

• Monitoring: continuous pulse oximetry and capnography where feasible (especially ventilated); observe for bleeding, subcutaneous emphysema, tube displacement
• Humidification: essential to prevent thick secretions and tube blockage (heated humidifier or HME filter as appropriate)
• Suction and inner cannula care: regular assessment; ensure staff trained; emergency equipment at bedside (suction, spare tube same size and one size smaller, bougie, scissors)
• Cuff pressure: maintain 20–30 cmH2O (reduce mucosal ischaemia; prevent aspiration/air leak)
• Communication and swallowing: consider speaking valve when appropriate; SALT review; aspiration precautions
• First tube change: usually by experienced operator; timing varies (often ≥5–7 days for open; may be earlier in selected cases); avoid early change if immature tract

Complications

• Immediate: haemorrhage (thyroid/venous), loss of airway/misplacement (false passage), pneumothorax/pneumomediastinum, subcutaneous emphysema, posterior tracheal wall injury, oesophageal injury, aspiration, hypoxia, arrhythmias
• Early (hours–days): tube blockage (secretions/blood clot), tube displacement (especially <7 days), infection/cellulitis, cuff leak, granulation, tracheitis
• Late: tracheal stenosis (subglottic/tracheal), tracheomalacia, tracheo-oesophageal fistula, tracheo-innominate fistula (catastrophic), persistent stoma, dysphonia, swallowing dysfunction
• Risk factors for displacement/false passage: obesity, short neck, agitation, inadequate fixation, early post-op period (immature tract), excessive tube length/poor sizing

Emergency management of tracheostomy problems (ward/ICU)

• General principles: call for help early; apply high-flow oxygen to face AND tracheostomy; assess patency; use capnography for any ventilatory attempt
• Blocked tube suspected: remove inner cannula (if present) → suction → if still obstructed, deflate cuff (if safe) and reassess airflow → remove tube if needed
• Displaced tube suspected: do not blindly push back; remove tube and oxygenate; if stoma mature, consider replacement with same size or smaller tube over bougie/fibreoptic; if not mature, prioritise oral intubation and cover stoma
  • Mature stoma: typically after ~7 days (variable); replacement more likely to succeed
  • Immature stoma: high risk false passage; oral intubation usually safest
• If patient has a laryngectomy (no upper airway): oxygenation/ventilation must be via stoma only; face oxygen is ineffective
• Ventilation options: bag-valve-mask with paediatric mask over stoma; tracheostomy tube; cuffed ETT into stoma (careful depth); oral intubation if upper airway patent and stoma not a laryngectomy
• Bleeding: minor oozing common early; brisk bleeding or sentinel bleed may indicate tracheo-innominate fistula—treat as life-threatening

Tracheo-innominate fistula (TIF): recognition and immediate actions

• Typically 3 days–6 weeks post-tracheostomy; may present with small 'sentinel' bleed then massive haemorrhage
• Immediate management: call for help, activate major haemorrhage; hyperinflate cuff (tamponade); apply digital compression through stoma (Utley manoeuvre) against sternum; secure airway (often oral intubation with cuff distal to bleed) and urgent surgery/IR
• Do not deflate cuff if bleeding significant; avoid repeated tube changes