Tracheostomy

About Tracheostomy

Tracheostomy is a surgical opening made through the front of the neck into the trachea, into which a tube is placed to provide an airway. Indications include the need for prolonged mechanical ventilation, upper airway obstruction from tumors, swelling or trauma, paralysis of both vocal cords, severe obstructive sleep apnea not responding to other treatments, and neurological conditions that impair the ability to protect the airway and clear secretions. Compared with a prolonged tube through the mouth, a tracheostomy can improve comfort, reduce sedation needs, make secretions easier to clear and help weaning from the ventilator. The optimal timing in critically ill patients has been studied in randomized trials without a clear advantage for very early tracheostomy. In open surgical tracheostomy, a horizontal incision is made in the lower neck, the strap muscles are separated, the thyroid isthmus is divided or retracted, and an opening is made in the trachea below the cricoid cartilage, usually around the second to fourth tracheal rings. Percutaneous dilatational tracheostomy, based on the Seldinger technique and popularized by Pasquale Ciaglia in the 1980s, is commonly performed at the bedside in intensive care, often with bronchoscopic guidance. Complications include bleeding, displacement or blockage of the tube, infection of the stoma, pneumothorax, narrowing of the trachea and, rarely, a fistula into the esophagus or erosion into the innominate artery, which can cause catastrophic bleeding. Speaking valves allow many patients to talk, and the tube is removed in a process called decannulation when the underlying problem has resolved. Emergency surgical airways are usually made through the cricothyroid membrane instead.