Tracheostomy, tracheotomy, and cricothyroidotomy are surgically created airway openings directly into the trachea below the vocal cords. In many ways, the airway is greatly simplified because the upper airway has been circumvented; nevertheless, many physicians and other caregivers are stymied when they encounter a problem with a surgical airway. Understanding the anatomy resulting from the different surgical approaches and knowing how to manage some common complications can alleviate the fear and frustration associated with airway compromise in this patient population.

A tracheostomy, or tracheal stoma, is most often created when a patient undergoes a laryngectomy. In this case, the trachea is diverted to the neck, and there is no connection between the trachea and any upper airway structures. The only way to access the lungs of these patients is via the tracheal stoma (Fig. 56-1 A and B).

A tracheotomy is a hole in the trachea that is made surgically through the front of the neck. The patient’s upper airway remains in continuity with the trachea, although depending on the reason for the procedure, the upper airway anatomy may or may not be normal. There are two ways to access the lungs of these patients: either through tracheotomy or through the upper airway (Fig. 56-2 A, B and C).

In an airway emergency, the trachea may be surgically approached through the cricothyroid membrane, using a procedure called a cricothyroidotomy. (See Chapters 36, Cricothyrotomy, and 37, Wire-Guided Cricothrotomy) This creates an opening into the airway through the neck and cricothyroid membrane just below the vocal cords. This is a temporary airway, typically created under emergency conditions to provide oxygen to the patient until a formal tracheotomy or other airway access can be obtained, although this is somewhat controversial.⁷ The upper airway of the patient is intact, but the reason for requiring an emergency surgical airway is often due to abnormal or injured upper airway structures, so it may be very difficult or impossible to approach the trachea from above.

Although these different approaches may not seem complicated, failure to recognize how the trachea has been surgically altered can lead to poor decision making in an airway crisis. The most likely problems one will encounter differ somewhat with each type of surgical approach.

A tracheostomy generally requires no equipment, such as a tube, to remain patent. Patients often wear a cloth cover to preserve their appearance and protect their airway from dust and debris. Healthcare providers must be careful not to overlook the patient’s actual airway in a medical emergency. Oxygen given via nasal cannula or face mask, for example, will not reach the patient’s lungs; supplemental oxygen must be administered over the tracheal stoma to be effective.

Positive pressure ventilation provided by a normal bag-valve-mask apparatus to the face will only inflate the patient’s stomach. If a patient with a tracheostomy requires positive pressure ventilation there are two options: (1) application of a small mask to the neck over the tracheal opening, or (2) insertion of a cuffed tube (either an endotracheal tube or a tracheotomy tube) into the ostomy with positive pressure via this tube.

A tracheotomy will typically close over time unless there is a tube or a plug in place to keep it open. People with a tracheotomy tube who are breathing spontaneously may be breathing through their nose and mouth or through their tracheotomy or both. If in respiratory distress, the patient may be experiencing a blocked or partially blocked airway (upper or lower) or they may need assistance with ventilation due to poor ventilatory mechanics or acute illness (ie, pneumonia or pulmonary edema). The underlying cause of respiratory distress should be determined quickly so that the proper treatment can be initiated early.³

Patients who require positive pressure ventilation through a tracheotomy tube should have a cuffed tracheotomy tube in place. These tubes have a pilot balloon attached to the cuff that hangs down on the outside (Fig. 56-3). It is possible for these cuffs to rupture or leak and no longer provide a seal between the tube and the trachea. More commonly, the patient who no longer requires positive pressure ventilation will have the cuff deflated or a new tube may be placed that has no cuff. These long-term tubes are plastic or metal and may have fenestrations to allow air to flow through as well as around the tracheotomy tube, thereby allowing breathing through the vocal cords and upper airway, and making normal speech possible by externally occluding the tube.²,¹¹