A tracheotomy or tracheostomy is a surgical procedure performed on the neck to open a direct airway through an incision in the trachea (the windpipe). (Technically, the former term, with the Greek root tom- meaning "to cut," refers to the procedure of cutting into the trachea, whereas the latter term, with the root stom- meaning "mouth," refers to the procedure of making a semipermanent or permanent opening. Tracheostomy can also refer to the result of the procedure, i.e. the opening itself.)

Indications for tracheostomy

The indications for tracheostomy are:

• Acute setting - maxillofacial injuries, large tumors of the head and neck, congenital tumors, e.g. branchial cyst, acute inflammation of head and neck, and
• Chronic / elective setting - when there is need for long term mechanical ventilation and tracheal toilet, e.g. comatose patients, surgery to the head and neck.

In emergent settings, in the context of failed endotracheal intubation or where intubation is contraindicated, cricothyrodotomy or mini-tracheostomy may be performed in preference to a tracheostomy..

How a tracheostomy is performed

1. Curvilinear skin incision along relaxed skin tension lines (RSTL) between sternal notch and cricoid cartilage
2. Midline vertical incision dividing strap muscles
3. Division of thyroid isthmus between ligatures
4. Elevation of cricoid with cricoid hook
5. Placement of tracheal incision. An inferior based flap or Bjork flap (through second and third tracheal rings) is commonly used. The flap is then sutured to the inferior skin margin. Alternatives include a vertical tracheal incision (pediatric) or excision of an ellipse of anterior tracheal wall.
6. Insert tracheostomy tube (with concomitant withdrawal of endotracheal tube), inflate cuff, secure with tape around neck or stay sutures.
7. Connect ventilator tubing

You can also make a simple horizontal incision between tracheal rings (typically 2nd and 3rd) for the incision. Bjork flaps may produce more intratracheal granulation tissue at the site of the incisions, making it less favorable to some surgeons.

Complications

1. Immediate - pneumothorax or pneumomediastinum, tracheoesophageal fistula, injury to great vessels or recurrent laryngeal nerves, bleeding, e.g. from divided thyroid isthmus
2. Early - secretions and mucus plugging, disloged tube, respiratory arrest and post obstructive pulmonary edema (when tracheostomy is performed in a patient with longstanding upper airway obstruction, and is dependant on hypoxia drive for respiration)
3. Late - bleeding from tracheoinnominate fistula (can be torrential), tracheal stenosis (from ischemia induced by a cuffed tracheostomy tube)

Caring for a tracheostomy

Aaron's tracheostomy page

See also

• intubation
• mechanical ventilation