A. Benefits.

1. Improved patient comfort, decreased sedation requirements, and decreased work of breathing are thought to translate into improved ability to wean from the ventilator.

2. Tracheostomies provide the possibility for vocal communication in intermittently ventilated patients as well as allow for improved oral hygiene.

3. Reduced risk of laryngeal injury from prolonged endotracheal (ET) intubation.

B. Tracheostomies do not necessarily improve outcomes.

1. Performing “early” tracheostomy (<7 days) may improve some short-term outcomes but at the risk of some procedure-related complications. Early tracheostomies have not been shown to improve long-term outcomes when compared to tracheostomies performed later in the hospital course (around 7 to 14 days).

2. Tracheostomies are not clearly associated with increased rates of intensive care unit (ICU) or hospital survival or a decrease in the frequency of aspiration or nosocomial pneumonia.

C. There are currently a variety of techniques available for tracheostomy creation.

1. Surgical/open.

2. Percutaneous.

3. Semiopen.

D. These techniques allow for the procedure to be safely performed in a range of patient care settings by both surgeons and nonsurgeon practitioners.

1. Emergency department.

2. ICU.

3. Operating room.

A. The trachea occupies the neck and thorax immediately anterior to the esophagus as the distal continuation of the larynx.

B. It terminates at the carina or bifurcation (located at the level of the seventh thoracic vertebra) where it divides into the right and left main bronchi and subsequently into the lobar bronchi.

C. Rings.

1. The thyroid cartilage is the most superior cartilage and is easily palpable.

2. The cricoid cartilage is the only continuous ring of the trachea.

3. Between the thyroid and cricoid cartilages is a palpable indentation corresponding to the cricothyroid membrane. This is the site of access to the trachea during an emergent cricothyroidotomy.

4. Accepted site for tracheotomy is the second or third tracheal ring.

D. Special considerations in children.

1. The trachea is much shorter in children than in adults.

2. In children under the age of 9, tracheostomy rather than cricothyroidotomy is the procedure of choice in an emergency.

A. Airway obstruction secondary to thyroid tumors, pharyngeal abscess, or granulation tissue from prolonged intubation or tracheal irritation or severe inflammation due to asthma, trauma, or anaphylaxis.

B. Need for prolonged mechanical ventilation (median 11 days in a multicenter trial) in the setting of head injury, severe chronic obstructive pulmonary disease (COPD), quadriplegia, and high spinal cord injuries.

C. As an airway control strategy for patients undergoing facial or esophageal reconstruction.

A. In the elective setting, it is important to ensure that the patient is not clinically coagulopathic due to either liver disease or medications.

B. Obese patients require a larger incision and a longer cannula and may benefit from a procedure performed in the operating room where factors such as lighting and positioning may be more carefully controlled.

C. Caution should be used in patients with high positive end-expiratory pressure (PEEP) requirements (>10 cm H₂O) as during the procedure patients may experience alveolar derecruitment leading to hypoxemia and acute lung injury.

D. Subcutaneous and mediastinal emphysema are not contraindications to tracheostomy.

E. Patients with closed head injury and an elevated intracranial pressure (ICP) may not be appropriate for tracheostomy until the ICP is controlled. Percutaneous tracheostomy is particularly contraindicated as elevated PaCO₂ during bronchoscopy may further increase ICP.

F. Necks distorted by tumors, hematoma, or previous radical neck surgery.

G. An enlarged thyroid can be a source of uncontrolled bleeding and poor visualization.

H. A high-riding innominate artery especially in patients with large necks is a rare but important source of potential life-threatening bleeding.

A. Setup.

1. Unless extenuating circumstances exist, patients should receive general anesthesia.

2. It is important to inspect the surgical technicians table for the necessary equipment and test the tracheostomy cuff prior to beginning the procedure.

3. Anesthesia provider should release the ET tube holder and ensure all tape is ready for removal upon the surgeon’s request.

B. Positioning.

1. Do not overextend the neck and displace the second and third tracheal rings too far superiorly.

2. Maintain neutral positioning for patients with cervical spine injuries.

C. Procedure.

1. Perform a time-out.

2.

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