Technique of tracheostomy

Techniques of surgical tracheostomy
Peter A. Walts, MD, Sudish C. Murthy, PhD, MD, Malcolm M. DeCamp, MD*
Department of Thoracic and Cardiovascular Surgery, Section of General Thoracic Surgery, The Cleveland Clinic Foundation,
9500 Euclid Avenue, Desk F24, Cleveland, OH 44195, USA
Tracheostomy, from the Greek tracheo plus stoma
(mouth), strictly defined as the creation of a opening
in the trachea by suturing the skin of the neck to the
tracheal mucosa, has come to describe the placement
of a tube through the anterior neck into a tracheo-
tomy, or incision in the trachea. Though there is
evidence supporting the possibility that tracheos-
tomies date back to 3000 years BC [1], Asclepiades
in the first century BC clearly described their use for
the relief of upper airway obstruction, the principal
indication for the next 2000 years [2]. A surge in the
performance of tracheostomy in the eighteenth and
nineteenth centuries during the diphtheria epidemic
resulted in improvements in the technique, but mor-
tality in this setting was 73% [3]. Jackson, with his
description of the technique in 1909, is credited with
the establishment of the modern tracheostomy as a
safe and important part of the surgeon’s armamen-
tarium [4].
The advent of mechanical ventilators and intensive
care units in the 1950s drove a shift in the primary
indication for tracheostomy from emergent relief of
obstruction to elective support for prolonged ventilator
dependence. These innovations also prompted a dra-
matic increase in the use of tracheostomies [5]. Such
increased use of the procedure in the critically ill
patient, and the evaluation of associated complica-
tions, forced refinement of surgical technique and
tracheostomy tube design, and served as the impetuses
for the development of new, simpler approaches. Toy
and Weinstein introduced the percutaneous tracheos-
tomy in 1969 [6]. Their technique was modified by
Ciaglia in 1985 into the modern percutaneous dila-
tional tracheostomy [7], the preferred method of
bypassing the upper airway in some centers.
This article focuses on surgical tracheostomy: the
indications, techniques and complications of one of
the most commonly performed procedures in con-
temporary critical care medicine.
Indications and timing
Despite its long history and frequent use, the
indications and timing for tracheostomy remain con-
troversial. As with all surgical procedures, the poten-
tial benefits to the patient must be carefully weighted
against the risks. The comorbidities and variability of
presentation of patients requiring prolonged ventila-
tory support make establishing a set of rules govern-
ing the use of tracheostomies difficult. Aside from
those patients requiring permanent tracheostomy fol-
lowing laryngectomy, tracheostomy is indicated for
relief of upper airway obstruction, for management of
uncontrolled tracheobronchial secretions, and most
commonly for prolonged mechanical support due to
respiratory insufficiency [8]. The development of
fiberoptic bronchoscopy, laryngeal mask airways,
and translaryngeal endotracheal intubation allowed
for development of the elective tracheostomy. Crea-
tion of an emergent surgical airway is now usually
precipitated only by severe maxillofacial or laryngeal
trauma or significant inhalation injury. Other causes
of airway obstruction which may require a tracheos-
tomy include oropharyngeal tumors, severe angio-
neurotic edema, bilateral vocal cord paralysis, short
segment tracheomalacia, edema of the airway from
infection or surgery, foreign bodies, and sleep apnea
or the Pickwickian syndrome in the morbidly obese
[8]. In patients with an ineffective cough or excessive
0272-5231/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0272-5231(03)00049-2
* Corresponding author.
E-mail address: decampm@ccf.org (M.M. DeCamp).
Clin Chest Med 24 (2003) 413–422

secretions related to bronchiectasis, chronic pneumo-
nia, or neurologic or laryngeal dysfunction, tracheos-
tomy allows for effective pulmonary toilet [5].
The most common yet least clearly defined indi-
cation for tracheostomy is the requirement for pro-
longed mechanical ventilatory support due to
respiratory failure. The potential advantages of tra-
cheostomy in this setting include provision of a more
stable airway, protection against laryngeal injury,
improved pulmonary toilet and oral hygiene, a de-
creased requirement for sedation or restraints, facili-
tated ventilator weaning, potential for a shorter
intensive care unit stay, improved patient comfort,
and the potential for speech and oral feeding [9].
Although it is generally agreed upon that con-
version of an endotracheal tube to a tracheostomy is
indicated at some point during a critical illness,
opinions regarding the optimal timing and technique
for the procedure vary widely. Despite the large
body of literature addressing these issues, problems
with study design, the complexity and heterogeneity
of the patient population, differing practice patterns,
and differing operative techniques and complication
rates have confounded the search for an answer to
the question of timing [10]. Analysis of available
information allows one to draw some conclusions. It
is known that intubation, whether translaryngeal or
via tracheostomy, results in ischemia, ulceration, and
subsequent stenosis at pressure points between the
tube, its cuff, and the tracheal mucosa. The intro-
duction of high-volume, low-pressure cuffs in both
tracheostomy and endotracheal tube design has de-
creased the incidence of cuff-related airway stenosis,
but laryngeal injury and subglottic and tracheal
stenosis remain significant clinical problems [11].
In a prospective study of 200 patients, Whited found
a linear correlation between duration of intubation
and not only incidence, but also severity, of laryn-
geal injury. In those patients intubated less than
5 days there were no long-term complications. After
6 to 10 days there was a 5% incidence of chronic
stenosis, and those intubated for longer than 11 days
had a 12% incidence of chronic stenosis that was
consistently more extensive [12]. Although a num-
ber of studies in which the incidence of postintuba-
tion airway stenosis was extremely low have refuted
this correlation, differences in patient population and
the etiology for respiratory failure may account for
some of these differences [10,13–15]. Interestingly,
a second pattern of non–time-related, postintubation
laryngeal injuries such as hoarseness, arytenoid
dislocation, vocal cord paralysis, and glottic incom-
petence was uncovered at an incidence of 19% by
Colice et al [13]. These data argue against the role
of tracheostomy in preventing some forms of laryn-
geal injury.
Almost by definition, stenosis will occur to some
degree at the tracheal stoma; however, the incidence
of symptomatic tracheal stenosis is low, and com-
pared with laryngeal stenosis, much easier to treat. In
the patient meeting other criteria for conversion from
translaryngeal intubation to a tracheostomy, the risk
of stomal stenosis should not factor into the equation.
The primary argument against tracheostomy
revolves around the incidence of surgical complica-
tions, which again vary widely in the literature.
Stauffer reported a 66% complication rate with trache-
ostomy in contrast to a generally accepted 5% to 6%
[5,16]. Although his study is flawed by the wide
variability in surgeons’ experience and biased by not
accounting for the length of intubation before tracheos-
tomy, Stauffer correctly emphasizes the meticulous
technique and attention to detail required to achieve
good outcome in tracheostomy construction [16].
The optimal timing of elective tracheostomy
remains nebulous, and universal selection criteria
cannot be broadly applied. The choice to convert to
tracheostomy must be individualized based on a
number of factors. The approach that we encourage
sets a horizon some 7 to 10 days after intubation as the
first point in the decision tree. If a patient remains
intubated at this point and clearly is not going to be
extubatable in the next week, a tracheostomy should
be done, assuming an acceptable surgical risk and that
the patient is hemodynamically stable. Waiting this
initial week also will minimize the number of unnec-
essary tracheostomies. Beyond this point, the risk of
severe laryngeal injury, the need for a stable airway,
effective pulmonary toilet, and improved patient com-
fort begin to shift the risk-benefit ratio in favor of
tracheostomy. If the prognosis for recovery is uncer-
tain, careful daily reassessment of the patient’s prog-
ress over the next few days will allow accurate
prediction of the likelihood for extubation. We advo-
cate setting a limit between 10 and 14 days, at which
time a definitive decision is made. Though tradi-
tionally the bias has been to try to avoid tracheostomy,
our bias is that the benefits of early tracheostomy far
outweigh the risks of prolonged translaryngeal intu-
bation, which also include the risk of self-extubation
or reintubation for failed planned extubation.
Anatomy
Depending on the person’s size, the adult trachea
ranges from 10 cm to 13 cm in length from the larynx
to the carina. With the neck slightly extended, about
P.A. Walts et al / Clin Chest Med 24 (2003) 413–422414

half the length is above the thoracic inlet; however,
the trachea slides easily in the cephalo-caudal direc-
tion and there is tremendous variability in tracheal
orientation, depending on the position of the neck and
the patients body habitus. This becomes important
when attempting tracheostomy in the obese patient
with a short neck, or in the elderly patient with
kyphosis. In these cases the trachea may reside
almost entirely within the bony thorax [17]. The
shape of the trachea is dictated by incomplete carti-
laginous rings that extend laterally and anteriorly,
accounting for two thirds of its circumference and
leaving a flat posterior membranous wall in close
relation to the esophagus as they descend together
through the neck [17]. At the level of the thoracic
inlet the trachea dives from anterior to posterior,
passing behind the thymus, innominate vein, and
innominate artery; this further complicates tracheos-
tomy in the elderly, in whom this angle can approach
90 degrees [18].
Approaching the trachea anteriorly in the midline
beneath the platysma muscle, one encounters a su-
perficial cervical fascia, crossing branches of the
anterior jugular veins, the sternohyoid and sterno-
thyroid muscles, the thyroid isthmus, which crosses
the trachea at the level of the second ring, and a
pretracheal fat pad through which wander the inferior
thyroid veins and occasionally a thyroid ima artery
[18]. Dissection of the trachea laterally is unnecessary
during tracheostomy, and fraught with danger. The
blood supply to the cervical trachea is derived from
branches of the inferior thyroid artery that approach
the trachea laterally and form a longitudinal plexus
running alongside the trachea, near the cartilaginous-
membranous junction [18]. Lying in the tracheo-
esophageal groove as they ascend to the larynx are
the recurrent laryngeal nerves.
Standard open tracheostomy technique
Surgical tracheostomy is routinely done under
general anesthesia in the operating room. The opti-
mum position is supine with maximal neck extension,
facilitated by placement of a towel roll beneath or
between the patient’s scapulae. History of an unstable
cervical spine, spinal stenosis, kyphosis, or severe
cervical osteophyte disease may preclude extension
of the neck. Appropriate head and neck support must
be given and access to the trachea may require
division of the thyroid isthmus. In the absence of
any obvious contraindication, however, hyperexten-
sion of the neck can elevate up to half the trachea into
the operative field.
The anesthesia team is asked to facilitate eventual
removal of the existing endotracheal tube by partially
undoing the circumferential wrap used to secure the
tube. This avoids a struggle in the case when the
patient is draped and access to the face is obscured.
After a standard sterile surgical preparation, a 2 cm to
3 cm transverse incision is made crossing the midline,
about 2 cm above the suprasternal notch (Fig. 1). The
specific location and length of the incision will vary
according to patient factors such as location of the
cricoid cartilage, obesity, prior neck surgery, or recent
median sternotomy. In this not infrequent scenario,
the incision is made slightly higher to distance the
tracheostomy from the sternal incision, decreasing the
risk of contaminating the recently dissected medias-
tinal tissues. The subcutaneous tissue and platysma
muscle are divided transversely entering the sub-
platysmal plane (Fig. 2). The remainder of the dissec-
tion is done longitudinally. Division of the superficial
cervical fascia reveals the midline between the strap
muscles. Communicating venous branches may need
to be divided, but anterior jugular veins should be
lateral to the dissection and rarely require ligation.
Gentle lateral retraction of the sternohyoid and ster-
nothyroid muscles helps to develop the midline and
brings the thyroid gland into view (Fig. 3). The
pretracheal fascia and fibrofatty tissue are incised
inferior to the thyroid isthmus, and retractors moved
inferiorly, exposing the anterior surface of the trachea.
Fig. 1. The patient is positioned supine with the neck
extended. A transverse incision is fashioned about 2cm above
the suprasternal notch and below the cricoid cartilage.
P.A. Walts et al / Clin Chest Med 24 (2003) 413–422 415

It is very rarely necessary to divide the thyroid
isthmus, which in most cases can be elevated. Skilled
superolateral retraction by the assistant with the lips of
the retractor beneath the strap muscles, catching the
edge of the isthmus or the under surface of the thyroid
lobes, provides excellent exposure of the underlying
tracheal rings. Care must be taken to avoid avulsing
small veins that may drain directly into the innominate
vein, and if present, the thyroid ima artery needs to
be ligated.
Complete homeostasis is mandatory at this time,
as visualization of the wound after insertion of the
tracheostomy tube is limited. Before creating a
tracheotomy, a systematic check is made of the
instruments and the selected appliance. A range of
tracheostomy tubes should be immediately available
and the size of tube chosen depending on the size of
the patients trachea. The cuff is inflated, checked for
leaks and deflated. Care should be taken to fully
deflate and lubricate the cuff to avoid its getting
caught and torn by the cut edge of a calcified
tracheal ring. A #15 knife blade, tracheal hook,
and tracheal dilators should be readily available.
The midline is identified, the tracheal rings carefully
counted, and lateral traction sutures are placed
around the second or third tracheal ring (Fig. 4).
Frequently adequate exposure can be maintained by
gentle retraction on these sutures. If necessary, the
trachea can be further elevated using the tracheal
hook under the cricoid cartilage. A vertical linear
tracheotomy is created in the midline, ideally be-
tween rings 2 and 4, and gently dilated. The use of
electrocautery is avoided to prevent airway ignition.
Position of the tracheotomy is important, as injury to
the first ring or cricoid cartilage may increase the
risk of subglottic stenosis and placement of the
tracheotomy too low may pull the tracheostomy tube
or its balloon against the innominate artery. The
laterally placed sutures provide enough distraction to
have the endotracheal tube withdrawn under direct
vision to a point just proximal to the tracheotomy,
allowing for unobstructed passage of the tracheos-
tomy tube distally and easy reinsertion of the endo-
tracheal tube if necessary. The use of a cruciate
Fig. 2. The subcutaneous tissue and platysma muscle are
divided transversly entering the subplatysmal plane.
Fig. 3. Gentle lateral retraction of the strap muscles helps
develop the midline and expose the underlying thyroid
gland and trachea. Rarely it is necessary to ligate anterior
jugular veins.
Fig. 4. The thyroid isthmus is retracted cephalad and lateral
traction sutures placed around the 2nd or 3rd tracheal ring.

incision or resection of any portion of the anterior
tracheal wall is avoided to minimize the size of the
tracheotomy in hopes of decreasing the subsequent
stomal stenosis. For this reason aggressive dilation
of the tracheotomy should also be avoided, though
often some degree of laterally oriented dilation is
required (Fig. 5). The tracheostomy tube is passed
into the airway, the cuff inflated, and ventilation
resumed, directly across the operative field. Ease of
oxygenation, return of CO2, confirmed by the mass
spectometer and direct inspection with auscultation,
confirms proper tube placement. Only then may the
orotracheal tube be completely removed. The skin is
sutured loosely around the tube with absorbable
suture and the flange of the tracheostomy secured
to the skin in all four quadrants. Finally the appa-
ratus is further secured by the passage of a tracheal
tie around the neck. We do not advocate retaining
the traction sutures placed to facilitate tube place-
ment. Although they are helpful in the operating
room with optimal patient positioning and superior
lighting, they are not helpful in replacing a dis-
lodged fresh tracheostomy tube. This urgent situa-
tion is best handled by oral reintubation followed by
elective tracheostomy revision in the operating
room. Use of traction sutures to blindly replace a
fresh tracheostomy tube can easily lead to misplace-
ment of the tube into the mediastinum.
Special circumstances
Although it has become popular in some centers,
performing tracheostomy in the intensive care unit
(ICU) involves some degree of compromise. The
patient’s bed is softer and wider than the operating
table, limiting exposure and increasing the reach for
the surgical team. Additionally, the lighting is almost
always inadequate unless a headlight is worn. Bed-
side tracheostomy is recommended only when the
risk of transporting the patient outweighs the risk of
operating in a compromised environment.
A number of circumstances may arise that require
modification of technique. Unfavorable anatomy is
encountered in patients with obese and stout necks,
goiters, cervical stenosis, kyphosis, or previous neck
operations (Fig. 6). In the morbidly obese patient,
excessive soft tissue and a short neck hampers
identification of landmarks and challenge exposure.
Maneuvers such as caudal distraction of the shoul-
ders, taping of the submental skin, and elevating the
head of the bed 30° to 45° improve access to the
neck. The use of a longer incision provides valuable
additional exposure, and a cricoid hook is helpful in
pulling the buried trachea anteriorly and superiorly.
Because the final distance of the airway from the
skin is greater than usual and difficult to predict, it is
wise to use a fiberoptic bronchoscope to confirm
Fig. 5. #15 blade scapel is used to create longitudinal tracheostomy. The laterally placed traction sutures provide enough
distraction to allow for tracheostomy tube placement without excessive dilation. After confirming tube placement the traction
sutures are removed.

proper placement, with the tube orifice centered in
the distal trachea. Too short a tube leads to mal-
position of the orifice that often abuts the membra-
nous airways. Use of a longer tube, such as the
Rusch product (Willy-Rusch AG, Kemen, Germany)
with an adjustable flange that allows alteration of the
shaft length to prevent a catastrophic accidental
decannulation, is recommended.
The elderly can also provide unique challenges. It
may not be possible to extend an arthritic, kyphotic
neck, significantly decreasing the length of available
cervical trachea. Furthermore, calcification of the
tracheal rings is seen with advancing age or previous
irradiation; this can make incision with a knife blade
impossible. These patients will often require division
and ligation of the thyroid isthmus for tracheal
exposure (Fig. 7). The cricoid hook is used for
stabilization, and to deliver the proximal trachea into
the field. Heavy scissors are necessary to create the
tracheotomy, and if needed, a small window in the
anterior trachea to allow for tube placement without
cracking the airway from excessive blunt dilation
(Fig. 8).
Cricothyroidotomy
Though thought by some to be safe in the elective
setting [19], cricothyroidotomy is generally reserved
for emergency situations when standard means of
translaryngeal intubation are impossible or have
failed. Cricothyroidotomy is associated with a histori-
cally high rate of difficult-to-manage subglottic ste-
nosis [20]. When forced to obtain a surgical airway in
an emergency, a cricothyroidotomy is preferable
because of the procedure’s relative speed and sim-
Fig. 6. In the obese or a kyphotic neck, the distance from
trachea to skin will be increased. Inthis case a cricoid hook
can be used to pull the trachea anteriorly. Use of a longer
tube is often necessary and fiberoptic bronchoscopy to
confirm proper endoluminal placement is recommended.
Fig. 7. If the neck cannot be extended ligation, division
of the thyroid isthmus will expose a greater length of the
underlying trachea.
Fig. 8. Heavy scissors are used to create the tracheotomy if
the tracheal rings are thickly calcified.

plicity. It is important, especially in this setting, to
maintain a calm, systematic approach. A sterile field
should be prepared if at all possible, and a roll placed
beneath the shoulders unless there is some concern
for cervical spine stability. The laryngeal prominence
is the most reliable landmark. Using this as a guide,
palpation along the midline inferiorly toward the
sternal notch allows identification of a small depres-
sion, the cricothyroid membrane, immediately above
the cricoid cartilage. In the emergency setting a
vertical incision is preferable, as it avoids injury to
the anterior jugular veins minimizing bleeding and
allows for some leeway in placement. The incision
should be carried through the skin and subcutaneous
tissue to the thyroid cartilage. The cricothyroid mem-
brane is identified and incised along its inferior
border transversely, and a tracheal hook is inserted
under the thyroid cartilage. Gentle vertical dilation is
needed, enough to allow passage of a 6 mm or 7 mm
tube, but care should be taken to avoid damage to the
inferior edge of thyroid cartilage, thus reducing the
risk of subglottic stenosis. The tube can then be
inserted and secured in the usual fashion. Though
there is some debate about the safety of cricothy-
roidotomy in regards to the incidence of subglottic
stenosis, it is our practice to convert these patients to
a standard elective tracheostomy in the next 24 to
48 hours to negate this risk [21].
Percutaneous tracheostomies
Since its introduction by Toy and Weinstein in
1969 [6] and subsequent modification by Ciaglia [7],
percutaneous tracheostomies have enjoyed rapidly
increasing popularity. Advocates cite the ease of the
familiar technique, and the ability to perform the
procedure at the bedside, often by nonsurgical practi-
tioners [22]. Briefly, using a modified Seldinger
technique with progressive dilation over a guide wire
under bronchoscopic guidance, a stoma, preferably
between the first and second, or second and third
trachea rings, is created large enough to accept a
tracheostomy tube [22]. The need for an emergent
airway, inability to palpate landmarks, coagulopathy,
an enlarged thyroid, and thickly calcified tracheal
rings are all relative contraindications for the proce-
dure [5]. The reported complication rates for both
percutaneous and open tracheostomy range widely
[23]. It is most likely that with an appropriate level of
experience and in the appropriate setting, both can be
done with equivalent morbidity.
A natural extension of the percutaneous dilational
tracheostomy is the minitracheostomy introduced by
Matthews and Hopkinson in 1984, for the manage-
ment of excessive pulmonary secretions in patients
without the need for mechanical ventilation [24]. This
procedure can also be done with proven effectiveness
and safety at the bedside using a commercially
available kit and a small-gauge catheter introduced
through the anterior tracheal wall [24].
Tube-free tracheostomy
To avoid the morbidity associated with an in-
dwelling tracheostomy tube expected to remain for
months to years, Eliachar developed the long-term,
tube-free tracheostomy. Common indications for the
procedure include obstructive sleep apnea, bilateral
vocal cord paralysis, neuromuscular disorders, ir-
reparable laryngotracheal stenosis, and severe chronic
pulmonary disease [25]. The procedure begins with a
horizontal omega-shaped skin incision extending be-
yond the lateral margins of the sternocleidomastoid
muscles and arching to the level of the cricoid
cartilage. Subplatysmal flaps are elevated inferiorly
to the level of the manubrium, laterally beyond the
sternocleidomastoid muscles, and superiorly to the
level of the hyoid bone. The thyroid isthmus is
divided and the two lobes mobilized enough to allow
them to be sutured gathering the accompanying strap
muscles, to the ipsilateral sternal tendon of the
sternocleidomastoid muscle. Excessive adipose tissue
is removed to provide adequate space for the flaps
without obstruction of the stoma. A superiorly based
anterior tracheal flap is created by elevating the
second and third tracheal rings, the margins of which
are then sutured to the edge of the superior skin flap.
The remaining exposed tracheal edges are sutured to
the corresponding skin flaps until a circumferential
noncollapsing mucocutaneous anastomosis is com-
pleted. The stoma is intubated until the patient is
stable and breathing spontaneously, at which time the
majority of patients may be decannulated. Careful, in-
hospital, local wound care for the ensuing week
allows for tube-free healing.
Since its original description, the tube-free trache-
ostomy has been further modified for selected
patients in a second stage procedure by passing a
muscular sling around the stoma, using the clavicular
head of the sternocleidomastoid muscle. Although the
majority of patients are able to develop fluent unaided
speech and physiologic clearance of secretions by
voluntary constriction of the stoma, the sling proce-
dure provides the ability to do the same, with minimal
detectable morbidity, for those who were previously
unable [25,26].

Tracheostomy selection
When selecting among the many available trache-
ostomy tubes, there are several factors to consider.
Important issues include tube diameter and length,
cuff design, use of an inner cannula, and the presence
or absence of a fenestration (Fig. 9). The size of the
tracheostomy can refer to its inner diameter, outer
diameter, or length. In general the smallest outer
diameter tracheostomy that satisfies the requirement
for intubation should be used. This principle will
minimize the risk of subsequent tracheal stenosis. In
the obese or kyphotic patient whose anatomy does
not lend itself to the use of a standard semirigid
tracheostomy tube, the adjustable length, flexible
wire-reinforced Rusch (Willy-Rusch AG, Kemen,
Germany) tube is an excellent option (see Fig. 9B).
This tube can be tailored to fit the neck size by
movement of the flange, and should be used when-
ever there is doubt about the security or position of a
standard fixed-length tube.
The smaller the tube diameter, the greater will be
the resistance to airflow through the tube, but the less
the obstruction of flow around the tube. If the
indication for tracheostomy is control of excessive
tracheobronchial secretions, the smallest tube that
allows for adequate pulmonary toilet is appropriate
so as not to impede spontaneous respiration. Even a
cuffless tube may suffice for this indication. If pro-
longed mechanical ventilatory support is the indica-
tion for tracheostomy, a cuffed tube that completely
seals the airway, preventing the loss of tidal volume,
is required. A cuff design which provides this seal at
an inflated pressure less than 25 mm Hg is optimal
[27]. The use of an appliance with an inner cannula
provides a safe and simple mechanism for cleaning
the tracheostomy; however, these designs decrease
the internal diameter of the tube by 1 mm to 2 mm
and may therefore require selection of a larger outer
diameter tube (see Fig. 9C,D) [27].
Cuff design has evolved from the original low-
volume, high-pressure cuffs to high-volume, low-
pressure balloons to minimize the risk of pressure
necrosis of the tracheal wall and subsequent tracheal
stenosis or trachea-esophageal fistula [28,29]. Antici-
pating the patient’s requirement for ventilatory support
can influence the choice of cuff design. In the patient
with multiorgan failure and a long-term need for
Fig. 9. Examples of available appliances: (A) Bivona TTS, Bivona Medical Technologies, Gary, IN. Note the deflated cuff is
flush with the tracheostomy tube (tight to shaft). (B) Flexible wire-reinforced, adjustable-length tube, Willy-Rusch AG, Kemen,
Germany. The mobile flange is not included in the picture. (C) Fenestrated Shiley, Mallincrodt Inc., St. Louis, MO. Passage of air
through the fenestration allows for phonation with the tube capped. (D) Shiley XLT, proximal extension. Note the extended
length of the proximal portion from elbow to flange.

positive pressure ventilation, one might chose a
Shiley (Mallincrodt, Inc., St. Louis, MO) with a
large-volume, low-pressure, air-filled balloon. Con-
sidering the substantial additional resistance to airflow
around these larger outside diameter tubes with the
deflated cuff occupying the airway, this choice can
make spontaneous respiration around the tube or
speech very difficult [30]. As the patient recovers
and is ready to wean, conversion to a different tube
is often advisable. In the patient expected to require
only intermittent support, tube and cuff selection can
be addressed in two ways. One may choose to use a
tight-to-shaft Bivona tube (Bivona Medical Technolo-
gies, Gary, IN), in which case the balloon is high
pressure, saline filled, but when deflated is flush with
the tube, which has no inner cannula (see Fig. 9A).
Alternatively, a fenestrated tube may be used, which
markedly reduces resistance by permitting the flow of
air through the lumen of the tube when the appropriate
fenestrated inner cannula is inserted [30] (see Fig. 9C).
The fenestrated tube is ideal in the spontaneously
breathing patient, as it allows for easy phonation with
the tube capped, and can be blocked with an inner
cannula to prevent leak of delivered tidal volume in
the patient requiring mechanical support. Fenestrated
tubes may, however, complicate patient care. The
fenestration must be centered in the tracheal lumen
to function properly. If the tube is too short the
fenestration will be displaced anteriorly into the
pretracheal space, resulting in subcutaneous emphy-
sema or obstruction to spontaneous respiration. Ad-
ditionally, the fenestration is a nidus for the formation
of granulation tissue that may cause bleeding or
obstruction of the tube, complicating its removal
[27]. Problems with position of the tube are not
uncommon and the fenestrated tubes require vigilant
surveillance and frequent changing.
Complications
Tracheostomy, often considered to be a simple
procedure relegated to the most junior members of
the surgical team is, in fact, fraught with potential
complications. Though covered at length in another
article, a review of surgical complications is pertinent
to a discussion of technique. Intraoperative compli-
cations are technical in nature and as such are
avoidable. Bleeding during the procedure is rare
and usually easily controlled by judicious use of
electrocautery or suture ligation when necessary.
Known coagulopathy should be corrected preopera-
tively. Problems arise when dissection strays from the
midline, as their proximity puts the carotid arteries
and internal jugular veins at risk if dissection is
lateral, or the innominate artery at risk if dissection
is too inferior [32]. Similarly, due to their position in
the tracheoesophageal groove, overly vigorous lateral
retraction or dissection along the side of the airway
risks injury to the recurrent laryngeal nerves [32]. The
pleura may extend above the level of the clavicles
medially, especially in the presence of emphysema or
in children; this leads to a reported 0.9% to 5%
incidence of post-tracheostomy pneumothorax [31].
Failure to adequately expose and control the trachea
increases the likelihood of creating a false passage
into the surrounding soft tissue, which, if followed by
positive pressure ventilation, creates pneumomedias-
tinum and may lead to pneumothorax. Furthermore,
disruption of the surrounding tissues creates potential
space in which paratracheal abscess may arise.
These complications require prompt drainage and
broad-spectrum antibiotics. Benign subcutaneous
emphysema may develop as the patient coughs if
the dressing surrounding the tracheostomy is occlu-
sive, or the cuff is not fully inflated [32].
Acute tracheoesophageal fistula is the result of
inadvertent puncture of the posterior tracheal mem-
brane into the esophagus, usually when performing the
tracheotomy. This is protected against to some degree
by the underlying endotracheal tube, but one must be
cognizant of the risk and avoid excessive force when
incising the anterior tracheal cartilage. When con-
fronted with the calcified trachea, use of heavy scissors
to divide the rings affords greater control (see Fig. 8). If
recognized intraoperatively, the injury should be
repaired at the time of the tracheostomy.
The combination of nitrous oxide or concentrated
oxygen and electrocautery creates the potential for
fire in an airway, as has been reported a number of
times in the literature [33,34]. This dramatic compli-
cation can be avoided by minimizing the concentra-
tion of inspired oxygen, avoiding nitrous altogether,
and by not using cautery at all with the airway
opened. Hemostasis should be complete before the
tracheotomy, not only to avoid the urge to use cautery
but for optimal visualization.
Summary
Tracheostomy has become one of the most com-
monly performed procedures in the critically ill pa-
tient. Variations in technique and expertise have led to
a wide range of reported procedural related morbidity
and rarely mortality. The lack of prospective, con-
trolled trials, physician bias and patient comorbidities
further confound the decisions regarding the timing of

tracheostomy. With careful attention to anatomy and
technique, the operative complication rate should be
less than 1%. In such a setting, the risk-benefit ratio of
prolonged translaryngeal intubation versus tracheos-
tomy begins to weigh heavily in favor of surgical
tracheostomy. At exactly what point this occurs
remains undefined, but certainly by the tenth day of
intubation, if extubation is not imminent, arrange-
ments should be made for surgical tracheostomy by a
team experienced with the chosen technique.
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