OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

TRACHEOSTOMY Johan Fagan

Tracheostomy refers to the creation of a Coagulopathy: A coagulopathy should be

communication between the trachea and the corrected prior to surgery. If not complete-
overlying skin. This may be done either by ly corrected, then have electrocoagulation
open or percutaneous technique. This available at surgery to aid haemostasis
chapter will focus on the open surgical
technique in the adult patient. Cardiorespiratory status: Patients with up-
per airway obstruction may have cor pul-
Indications monale, or respiratory acidosis. Some
patients may be dependent on physiologi-
Tracheostomy is done for airway obstruct- cal PEEP to maintain O2 saturation, or an
tion, respiratory support (assisted ventila- elevated pCO2 to maintain respiratory
tion), pulmonary hygiene, elimination of drive; relieving upper airway obstruction
dead space, and treatment of obstructive with a tracheostomy may paradoxically
sleep apnoea. cause such patients to stop breathing and
become hypoxic.
Preoperative evaluation
Laryngeal cancer: If airway obstruction is
Level of obstruction: A standard tracheos- as a consequence of laryngeal cancer, then
tomy will not bypass obstruction in the one should attempt not to enter the tumour
distal trachea or bronchial tree during tracheostomy. This may require a
lower tracheostomy if tumour involves the
Anatomy of the neck: The surgeon should cervical trachea. It is prudent to send a
anticipate a difficult tracheostomy in pa- sample from the tracheal window for histo-
tients with short necks, thick necks, and logical examination as involvement by
necks that cannot be extended due to e.g. tumour might be useful information for the
rheumatoid or osteoarthritis of the cervical surgeon subsequently doing the laryngec-
spine tomy.

Deviation of cervical trachea: A chest X- Tracheostomy procedure

ray will alert the surgeon to tracheal
deviation due to cervical and mediastinal A tracheostomy is best done in the
tumours, or traction on the trachea due to operating room with good lighting,
fibrosis (Figure 1). instrumentation, suction, and assistance.
Patients may cough on inserting the
tracheostomy tube; hence eye protection is
recommended to prevent transmission of
infections such as HIV and hepatitis.

Anaesthesia: Unless the patient can safely

be intubated or the patient be ventilated
with a mask, a tracheostomy should be done
under local anaesthesia. If there is concern
about the anaesthetist’s ability to maintain
an airway, then the surgeon should be
present during induction; the skin, soft
Figure 1: Tracheal deviation due to tuber-
tissue and trachea (into the lumen) should
culosis
be infiltrated with local anaesthesia with veins, which are just superficial to the strap
adrenaline before induction; and a set of muscles within the investing cervical fas-
tracheostomy instruments should be set out cia, and can be preserved and retracted
before induction of anaesthesia so that an laterally (Figure 3).
emergency tracheostomy can be done if
required.

Positioning and draping: The patient is

placed in a supine position with neck
extended by a pillow or sandbag placed
under the shoulders in order to deliver the
trachea out of the thorax and to give the
surgeon adequate access to the cervical
trachea. Such extension may not be possi-
ble in patients with neck injuries, or rheu-
matoid and osteoarthritis of the cervical
spine. Some patients with impending air-
way obstruction may not tolerate a recum-
bent position; the tracheotomy may then be
done with the patient in a sitting position
with neck extended. The skin of the ante- Figure 2: Minimum set of instruments
rior neck and chest is sterilised and the neck
draped. If the tracheostomy is being done
under local anaesthesia, the face should not
be covered.

Surface landmarks: The tracheostomy is

created below the 1st tracheal ring, so as to
avoid subglottic stenosis as a result of
scarring. Therefore palpating to determine
the location of the cricoid cartilage is
important. When you run your fingers up Figure 3: Exposure of anterior jugular
the midline of the neck starting inferiorly at veins and cervical fascia
the sternal notch, you 1st encounter
prominence of the thyroid isthmus, follow- The remainder of the dissection should
ed by the cricoid. remain strictly in the midline in a vertical
plane to avoid injury to the inferior thyroid
Minimum instruments: A minimum set of veins.
instruments is demonstrated in Figure 2.
Infrahyoid strap muscles: Figure 4 illustra-
Skin incision: A horizontal incision is made tes the infrahyoid strap muscles. Identify
one fingerbreadth below the cricoid the midline cervical fascial plane between
prominence. This is cosmetically preferable the sternohyoid muscles. Divide this inter-
to a vertical midline incision. The incision muscular plane by spreading with a pair of
is carried through the skin and the scissors. Repeat this manoeuvre to separate
subcutaneous tissue. Note that the platys- the sternothyroid muscles, and retract the
ma is generally absent in the midline. Take muscles laterally (Figure 5). The trachea
care not to transect the anterior jugular and cricoid can now be palpated.

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 Expose trachea: The infrathyroid trachea is
Thyroid cartilage
exposed anteriorly by carefully parting
overlying soft tissues with a pair of scis-
Cricoid cartilage
sors, taking care not to tear the inferior
Thyroid gland
thyroid veins. Ensure that the surgical field
Sternohyoid muscle is dry before proceeding, as it is difficult to
Sternothyroid muscle achieve haemostasis once the tracheostomy
tube has been inserted. Should there be
doubt about the location of the trachea, or
there be concern it being confused with the
carotid artery, aspirating air with a needle
Figure 4: Infrahyoid strap muscles attached to a syringe will confirm its loca-
tion.

Create tracheostoma: In the wake patient,

lignocaine may again be injected into
tracheal lumen prior to incising the trachea
and inserting the tube in order to reduce
coughing. Upward traction may be applied
to a tracheal hook inserted under a tracheal
ring to stabilise the trachea and deliver it
from the chest. The safest means to create a
tracheostomy in adults is by creating an
Figure 5: Retracting sternohyoid and ster- inferiorly based flap raised from the ante-
nothyroid muscles to expose the thyroid rior wall of the 3rd and 4th tracheal rings. A
gland silk traction suture is passed through this
anterior tracheal flap and loosely secured to
Thyroid isthmus: The thyroid isthmus the skin (Figure 7). Traction on the suture
overlies the 2nd/3rd tracheal rings. The facilitates reinsertion of the tracheostomy
isthmus should be retracted superiorly to tube in case of accidental decannulation.
expose the trachea (Figure 6). Only very Alternately one may remove an anterior
rarely does the thyroid isthmus need to be cartilage segment of the 2nd, 3rd or 4th
doubly clamped, divided, and (suture) tracheal rings.
ligated.

Back wall of trachea

Inferiorly based tracheal flap

Traction suture anchoring

the flap

Figure 6: Thyroid retracted superiorly and Figure 7a: Flap reflected inferiorly with
an inferiorly based flap cut (along red lines) traction suture attached to flap
in anterior tracheal wall

3
 Epiglottis

Glottis

Thyroid cartilage

Cricoid

Thyroid gland

Innominate artery

Sternum

Figure 8: Position of tracheostomy tube

If the ties are placed with the neck extended,

they are too loose when the patient flexes
the neck. The ties should be tight enough to
Figure 7b: Flap reflected inferiorly with admit no more than a single finger under the
traction suture attached to flap tape (Figure 9).

Insertion of tracheostomy tube: The

surgeon assesses the size of the trachea, and
selects the largest sized cuffed tracheo-
stomy tube that will comfortably fit the
tracheal lumen. Inject air into the tracheo-
stomy inflatable cuff to test the integrity of
the cuff. Insert the introducer into the
tracheostomy tube. If the patient has been
intubated, the anaesthetist is asked to slowly
withdraw the endotracheal tube, so that the
tracheostomy tube can be inserted under
direct vision. Advance the tube into the
trachea while applying traction to the silk Figure 9: Tracheostomy tube secured with
traction suture attached to the tracheal flap. Velcro tape
Ensure that the tube has been inserted into
the tracheal lumen, and not a false passage It is prudent to suture the tracheotomy tube
in the paratracheal soft tissues. Inflate the to the skin for the first few days to allow
cuff, attach the anaesthetic tubing, and maturation of the tracheocutaneous tract.
hand-ventilate until one has confirmed The sutures can then be removed and
correct placement of the tube within the traditional tracheotomy tapes can then be
trachea (Figure 8). Do not suture the skin used. Following free microvascular trans-
tightly around the tracheostomy tube, as this fer flap reconstruction, tracheostomy tapes
can promote surgical emphysema. should be avoided; the tracheostomy should
preferably be sutured to the suprastomal
Securing the tracheostomy tube: Tapes are skin, as tracheal tapes may cause jugular
threaded through the holes in the flanges of vein compression, thrombosis, and venous
the tracheostomy tube and passed around outflow obstruction and flap failure.
the neck and tied with the neck flexed.

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Pitfalls Choice of Tracheostomy Tube

High tracheostomy: It is important not to A variety of tube designs and materials are
place the tracheotomy above the 2nd tra- available. The choice of tube should con-
cheal ring, as inflammation may cause sub- form to the indication for which it is to be
glottic oedema, chondritis of the cricoid used. All tubes should have an inner
cartilage, and subglottic stenosis. cannula; this can safely be removed and
cleaned without a need to remove the outer
Low tracheostomy: A tracheotomy should cannula and hence endanger the airway.
not be placed below the 4th tracheal ring as: The following factors may influence the
 The distance between the skin and the choice of tube:
trachea increases inferiorly, which
makes tracheal intubation more difficult Tube diameter: Because airway resistance
 A low tracheostomy may compress and is related to the 4th power of the radius with
erode the innominate artery which laminar flow, and the 5th power of the radius
passes between the manubrium sterni with turbulent flow, it is important to select
and the trachea (Figure 8). This may a tube that that fits the trachea snugly. A
cause innominate artery erosion and range of sizes should be available. It also
fatal haemorrhage. This may be underscores the importance of keeping the
preceded by a so-called “sentinel bleed” tube clean, as accumulation of mucus
increases airway resistance not only by
Paratracheal false tract: Inadvertent extra- reducing the diameter, but also by causing
tracheal placement of the tracheostomy tube turbulent air flow.
can be fatal. It is recognised by the absence
of breath sounds on auscultation of the Tracheal seal: A cuffed, plastic tracheos-
lungs, high ventilatory pressures, failure to tomy tube is used to create a seal with the
ventilate the lungs, hypoxia, absence of trachea in patients on positive pressure
expired CO2, surgical emphysema, and an ventilation, and with fresh tracheostomy
inability to pass a suction catheter down the wounds (Figure 10) to prevent saliva or
bronchial tree, and on chest X-ray. blood entering the lower airways. The
cuffed tube may be replaced with an
Surgical emphysema, pneumomediastinum, uncuffed tube, either plastic or metal
and pneumothorax: Injury to the pleural (Figure 11) in patients who do not require
domes is more likely to occur in children, positive pressure ventilation once the tract
struggling patients and patients on positive between the skin and the trachea has
pressure ventilation. It can be complicated become well defined by granulation tissue
by a tension pneumothorax. Hence auscul- at 48hrs, and tracheostomal bleeding has
tation of the chest and a CXR should be settled.
performed after tracheostomy, especially in
ventilated patients. Surgical emphysema Tube material: Metal tubes are thinner
may also be promoted by suturing the walled, and hence have a better ratio of
tracheostomy wound around the tracheos- outer to inner wall diameter, thereby
tomy tube. optimising airway resistance (Figure 11).

Airway fire: Do not enter the trachea with

diathermy, as this may cause an airway fire
in a patient being ventilated with a high
concentration of oxygen.

5
 Figure 12: Tracheostomy tube with
adjustable flange

Tube shape: Laryngectomy patients re-

quire shorter tubes with a gentler curvature
to conform to the stoma and the trachea.
Figure 10: Plastic low pressure cuffed
tracheostomy tube with outer cannula, Neck Flange: The neck flange should
inner cannula and introducer (L to R) conform to the shape of the neck and fit
snugly against the skin to avoid excessive
tube movement, accidental decannulation,
and soft tissue trauma.

Phonation: Patients with uncuffed tubes or

fenestrated tubes (Figure 13) can phonate
by occluding the end of the tracheostomy
tube with a finger which permits air to
bypass the tube and to pass through the
larynx.

Figure 11: Metal tracheostomy tube with

outer cannula, inner cannula and
introducer (L to R)

Tube length: Patients with very thick necks

can be fitted with a tracheostomy tube with
a flange that can be adjusted up or down the
shaft of the tube (Figure 12). Tube length
may also need to be adjusted when the
carina is close to the tracheostoma or with
tracheal stenosis or tracheamalacia distal to
the tracheostoma that needs to stented by Figure 13: Fenestrated tracheostomy tube
the tube. Chest and neck X-rays are of value
to determine the required length.

6
Speaking valves fitted to the ends of means of a humidifier, heat and moisture
tracheostomy tubes are one-way valves that exchange filter, or a tracheostomy bib.
open on inspiration, but close on expi-
ration, thereby directing expired air through Pulmonary Toilette: The presence of a
the larynx and permit hands-free speech tracheostomy tube and inspiration of dry air
(Figure 14). irritates the mucosa and increases
secretions. Tracheostomy also promotes
aspiration of saliva and food as tethering of
the airway prevents elevation of the larynx
during swallowing. Patients are unable to
clear secretions as effectively as tracheos-
tomy prevents generation of subglottic
pressure, hence making coughing and
clearing secretions ineffective; it also dis-
Figure 14: Speaking valve that fits onto the turbs ciliary function. Therefore secretions
end of a tracheostomy tube and permits need to be suctioned in an aseptic and
hands-free speech atraumatic manner.

Fenestrated tubes with speaking valves are Cleaning the tube: Airway resistance is
particularly well suited to patients with related to the 4th power of the radius with
obstructive sleep apnoea, as they can have laminar flow, and the 5th power of the radius
normal speech by day with the valve in with turbulent flow. Therefore even a small
place, but uncap the tracheostomy tube at reduction of airway diameter and/or
night to ensure unobstructed breathing. conversion to turbulent airflow as a result of
secretions in the tube can significantly
Postoperative care affect airway resistance. Therefore regular
cleaning of the inner cannula is required
Pulmonary oedema: This may occur using a pipe cleaner or brush.
following sudden relief of airway obstruct-
Securing the tube: Accidental decannula-
tion and reduction in high intraluminal
tion and failure to quickly reinsert the tube
airway pressures. It may be corrected by
may be fatal. This is especially problema-
CPAP or positive pressure ventilation.
tic during the 1st 48hrs when the tracheo-
cutaneous tract has not matured and
Respiratory arrest: This may occur imme-
attempted reinsertion of the tube may be
diately following insertion of the tracheos-
complicated by the tube entering a false
tomy tube, and is attributed to the rapid
tract. Therefore the tightness of the tracheo-
reduction in arterial pCO2 following resto-
stomy tapes should be regularly checked.
ration of normal ventilation, and hence loss
Traction sutures on the tracheal flap
of respiratory drive.
facilitate reinsertion of the tracheotomy
tube.
Humidification: Tracheostomy bypasses
the nose and upper aerodigestive tract Cuff pressures: When tracheostomy tube
which normally warms, filters, and humi- cuff pressures against the tracheal wall
difies inspired air. To avoid tracheal desic- mucosa exceed 30cm H20, mucosal capil-
cation and damage to the respiratory cilia lary perfusion ceases, ischaemic damage
and epithelium, and obstruction due to ensues and tracheal stenosis may result.
mucous crusting, the tracheostomy patient Mucosal injury has been shown to occur
needs to breathe humidified warm air by within 15 minutes. Therefore cuff inflation

7
pressures of >25cm H20 should be avoided. 586fbaeba29d/Percutaneous dilational
A number of studies have demonstrated the tracheostomy surgical technique.pdf
inadequacy of manual palpation of the pilot
balloon as a means to estimate appropriate Paediatric tracheostomy
cuff pressures. Measures to prevent cuff https://vula.uct.ac.za/access/content/group/
related injury include: ba5fb1bd-be95-48e5-81be-
 Only to inflate the cuff if required 586fbaeba29d/Paediatric%20tracheostomy
(ventilated, aspiration) .pdf
 Minimal Occluding Volume Technique:
Deflate the cuff, and then slowly rein- Cricothyroidomy
flate until one can no longer hear air https://vula.uct.ac.za/access/content/group/
going past the cuff with a stethoscope ba5fb1bd-be95-48e5-81be-
applied to the side of the neck near the 586fbaeba29d/Cricothyroidotomy%20and
tracheostomy tube (ventilated patient) %20needle%20cricothyrotomy.pdf
 Minimal Leak Technique: The same
procedure as above, except that once the
airway is sealed, slowly to withdraw Author & Editor
approximately 1ml of air so that a slight
leak is heard at the end of inspiration Johan Fagan MBChB, FCORL, MMed
Professor and Chairman
 Pressure gauge: Regular or continuous
Division of Otolaryngology
monitoring of cuff pressures
University of Cape Town
Cape Town, South Africa
Decannulation
johannes.fagan@uct.ac.za
The tracheostomy tube can be removed
once the cause of the airway obstruction has THE OPEN ACCESS ATLAS OF
been resolved. If any doubt exists about the OTOLARYNGOLOGY, HEAD &
adequacy of the airway, e.g. following NECK OPERATIVE SURGERY
pharyngeal or laryngeal surgery, then the www.entdev.uct.ac.za
tracheostomy tube is first downsized and
plugged, so that the patient can breathe
freely past the tube. The tube is then
plugged. The patient should be under close The Open Access Atlas of Otolaryngology, Head & Neck
observation during this time, and may be Operative Surgery by Johan Fagan (Editor)
monitored with pulse oximetry. If the johannes.fagan@uct.ac.za is licensed under a Creative
Commons Attribution - Non-Commercial 3.0 Unported
patient can tolerate the tracheostomy tube License
being plugged overnight, it can then be
removed. The tracheostomy wound is
covered with an occlusive dressing, and
generally heals over a matter a week.

Related chapters

Percutaneous dilational tracheostomy

surgical technique
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ba5fb1bd-be95-48e5-81be-