Tracheostomies are placed for a variety of reasons, including prolonged respiratory failure, management of upper airway obstruction, and airway protection.¹ Emergent tracheostomies are life-saving procedures for patients in whom oral and nasal intubations cannot be successfully performed, such as airway obstruction, penetrating laryngeal injury, or LeFort III fractures with craniofacial dislocation.² Elective tracheostomies, which are performed in patients already orally or nasally intubated, can be used to facilitate weaning from mechanical ventilation and provide easier access for pulmonary toilet.² Tracheostomies are typically more comfortable and tolerable for patients than endotracheal tubes, allowing for decreased sedation needs and increased patient mobility.² The number of tracheostomies performed in the United States was over 100 000 annually in 2014 and continues to increase.³ It is vitally important for emergency providers to know about the management of tracheostomy emergencies, from bleeding to obstruction to infection.

Tracheostomies can be performed via an open surgical approach or percutaneous dilational technique (PDT). Surgical tracheostomies are safer to perform in patients with limited anatomic landmarks, history of prior tracheostomy, and coagulopathies.^4,6 PDT involves a modified Seldinger technique, usually under bronchoscopic or sonographic guidance.^4,5 It is associated with decreased procedural time, less bleeding, and a trend toward lower infection rates.⁴ PDT complications include tracheal laceration, arterial injury, and esophageal perforation. Multiple meta-analyses have shown that PDT can be performed at the bedside as safely as the open surgical approach.^5,6

Tracheostomy complications can arise because of the close proximity of the trachea with surrounding structures (Figure 17.1). The trachea is composed of 18 to 22 C-shaped cartilaginous rings anterolaterally and a membranous portion posteriorly.³ The cricoid cartilage is the top of the trachea; it is a complete ring, whereas the remaining tracheal rings are incomplete. The thyroid gland typically overlies the second to sixth tracheal rings. The recurrent laryngeal nerves are immediately lateral to the cervical trachea. The anterior jugular veins run vertically and close to midline, whereas the internal jugular veins and the carotid arteries are more lateral. The innominate artery crosses over the trachea between the sixth and ninth tracheal rings. Tracheostomies are placed most often between the second and third tracheal rings.³

It is also important to be familiar with the tracheostomy equipment (Figure 17.2). The outer cannula is the main body of the tracheostomy tube; if present, the inner cannula fits inside the tube and acts as a liner that can be removed and cleaned. The obturator, which is used only when placing a tracheostomy tube, acts as a guide; it has a smooth tip, which prevents airway damage during
insertion. Tracheostomy tubes can be cuffed or uncuffed. Cuffed tubes allow for positive pressure ventilation when inflated and can protect against aspiration.⁷ When a patient no longer requires mechanical ventilation, the cuffed tube can be exchanged for an uncuffed tube. Uncuffed and deflated tubes allow patients to speak. Cuffed tubes can lead to tracheal necrosis and stenosis if the tube is malpositioned or if prolonged use of high cuff pressures is needed to maintain an adequate seal. Tubes with foam cuffs exist for patients who have developed tracheal stenosis.⁷

There are a variety of sizes and styles of tracheostomy tubes, but the notable details of the tracheostomy tube are always located on the flange of the tube. The dimensions of the tubes are provided by the internal diameter, external diameter, length, and curvature.⁷ The internal diameter is the functional inner diameter, and the external diameter is the largest diameter of the outer cannula. Sizing systems differ between models and manufacturers.

If the tracheostomy tube is too short, the distal end of the tube may not reach the airway; extra length tubes can be used to mediate this problem.⁷ The tracheostomy tube shape should also follow
the airway anatomy as much as possible.⁷ Proximal extended length tracheostomy tubes, which have extra horizontal length, may be required in patients with thick or obese necks, whereas distal extension tracheostomy tubes, which have extra vertical length, may be required in patients with long tracheas, tracheal obstruction, or tracheomalacia.^3,7 Fenestrated tubes have additional openings in the posterior portion of the tube, allowing for air movement and better phonation; these tubes can be used in preparation for decannulation.⁷