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 &lt,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 &#039,sentinel&#039, 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

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