Surgical Technique for Tracheostomy

Indications and Considerations

The American Thoracic Society recommends considering tracheostomy in patients who require prolonged mechanical ventilation, particularly when ventilation is expected to be needed for more than 10-14 days, for patients with actual or anticipated airway obstruction, for management of secretions in patients unable to eliminate respiratory secretions due to inadequate laryngeal reflexes, and for patients with chronic respiratory failure, especially those with neurological disorders 1

The American College of Chest Physicians recommends that tracheostomy be performed in a negative pressure room, preferably in the ICU, using enhanced personal protective equipment (PPE) to mitigate the risk of infection 2, 3, 4
The technique for open surgical tracheostomy (OST) involves identifying the cricothyroid membrane, making an incision through the skin and platysma, advancing the endotracheal tube distal to the operative site before opening the trachea, hyperinflating the endotracheal tube cuff, pausing ventilation at key moments, and covering the operative site with gauze when ventilation is resumed 5, 4
The technique for percutaneous dilational tracheostomy (PDT) involves the same considerations for PPE and room setup as for OST, with the addition of considering the use of ultrasound to identify vasculature before the procedure, and using a bronchoscope to improve safety but increase the risk of aerosolization 5, 4

The procedure should be performed by a team with the fewest number of providers and the highest level of experience, with a focus on preventing aerosolization, especially in patients with COVID-19 2, 3, 4
The use of a negative pressure room in the ICU is preferred, but if not available, a negative pressure room in the operating room or a regular room with HEPA filters and a strict door policy can be used 2

Immediate complications of tracheostomy include bleeding and loss of the airway, while short-term complications include blockage or displacement of the tracheostomy tube, and long-term complications include tracheomalacia, tracheal stenosis, or stoma-related problems 6

Both OST and PDT are acceptable techniques for patients requiring prolonged mechanical ventilation, with the choice of technique determined by local experience and available resources 2, 4
Operators should only perform procedures with which they are familiar and competent, and confidence and experience are essential for any chosen technique 4

The most frequently used insertion point in adult practice is the inter‑space between the second and third tracheal rings, approximately 2 cm distal to the cricoid cartilage, and it is usually performed by percutaneous dilatational tracheostomy (PDT) in the intensive‑care setting. 7
Percutaneous dilatational tracheostomy is the predominant technique for adults, especially for critically ill patients who require prolonged mechanical ventilation. [8][7]
The procedural target is the inter‑cartilaginous space at or just below the second tracheal ring, ensuring placement within the optimal anatomical window. 7
Ultrasound guidance is recommended to delineate the tracheal anatomy and avoid adjacent vascular structures, thereby decreasing reliance on bronchoscopic assistance. 7
Selection between percutaneous dilatational tracheostomy and open surgical tracheostomy should be guided by the institution’s expertise and the resources available, rather than by patient factors alone. 7

In children, a vertical tracheotomy incision (rather than a cartilage window) is mandatory to minimise the risk of post‑operative stenosis. [9][8]
The paediatric airway is characteristically small, pliable, and difficult to palpate; the short neck and proximity of major vessels increase technical difficulty. [9][8]
Stay sutures are placed on either side of the vertical tracheostomy incision to facilitate rapid tube exchange before the stoma matures. [9][8]
Open surgical tracheostomy performed in the operating‑room is the standard approach for paediatric patients, contrasting with the percutaneous technique favoured in adults. [8][10]
Use of maturation sutures is advocated to accelerate stoma formation and promote stable healing in children. 9

Routine bedside ultrasound should be employed to confirm the level of the tracheal rings and to identify and avoid vascular structures such as the brachiocephalic artery before puncture. 7
Ultrasound‑guided site confirmation contributes to safer placement and may reduce the incidence of high or low tracheostomy complications. 7