Critically ill patients often require prolonged ventilator support that is facilitated by tracheostomy, one of the most common surgical procedures, to replace endotracheal intubation.¹ Tracheostomy can be performed at the bedside or in the operating room (OR). It can be performed open or percutaneously. The open surgical tracheostomy was first described in 1909 by Chevalier Jackson. In recent years, the number of tracheostomies performed has increased by nearly 200%²; however, there is significant variability in the timing and frequency of tracheostomy.³ Although the need for prolonged ventilator support and better access for suctioning the airway are the most common indications for tracheostomy, other indications include upper airway obstruction, severe facial and laryngeal trauma, radical oropharyngeal or thyroid surgery for advanced cancer, and neurologic disorders with inability to protect one’s airway. Patient comfort and facilitating nursing care of the airway may also play a role.

The classic open technique involves a horizontal incision approximately 2 cm above the sternal notch or a vertical incision extending from the inferior edge of the cricoid cartilage toward the suprasternal notch. The dissection is carried down to the trachea as described below and a tracheostomy tube is usually inserted between the second and third tracheal rings. It has also become common to perform tracheostomy percutaneously in the critically ill patient for prolonged ventilatory support.

There are many indications for tracheostomy, but the primary rationale behind performing tracheostomy is to facilitate prolonged ventilatory support in patients who fail to wean from the ventilator.⁴ There is much controversy and conflicting evidence regarding the appropriate timing of a tracheostomy. Potential advantages of early tracheostomy include decreased ventilator days, decreased length of stay in the intensive care unit (ICU), and decreased ventilator-associated pneumonia. Studies have shown that in patients with inadequate reserve, tracheostomy decreases work of breathing.⁵ Rumbak et al⁶ found in a prospective randomized trial that performing tracheostomy within 2 days of admission to ICU was associated with a reduced occurrence of pneumonia, fewer days on the ventilator, a 50% reduction in the 30-day mortality rate, and a shortened ICU stay compared with tracheotomies performed at 2 weeks. A meta-analysis of 5 clinical trials performed with a total of 406 patients comparing early tracheostomy, defined as within 7 days, versus late tracheostomy in ICU patients showed that mortality and pneumonia rates were similar in both groups. However, early tracheostomy significantly decreased ICU length of stay and days on mechanical ventilation.⁷ A recent practice management guideline for trauma patients recommended that early tracheostomy (within 3 to 7 days of admission) should be performed in patients with severe traumatic brain injury and in patients who are likely to require mechanical ventilation for more than 7 days.⁸

Despite the potential advantages of tracheostomy, as in any surgical procedure, there are well-documented complications that one must consider. In a meta-analysis of 1,212 patients, some of the more common complications included bleeding (5.7%) and infection (6.6%).⁹ Other complications included pneumothorax, subcutaneous emphysema, and esophageal perforation. One of the most feared acute complications is accidental intraoperative or postoperative decannulation with the inability to intubate the trachea via the oral route or recannulate the trachea secondary to an immature fistula tract. Long-term complications include tracheal stenosis, tracheoesophageal fistula, and trachea-innominate fistula. Notwithstanding these potential complications, the overall benefit of tracheostomy usually outweighs the risk of the procedure.