Tracheostomy can be performed via an open surgical technique or via a percutaneous dilational technique. Percutaneous tracheostomy is becoming more popular because it is at least as safe as the surgical approach and is likely associated with fewer complications, primarily bleeding and infection. The choice between the two techniques typically depends on operator preference.
Key anatomic landmarks include the thyroid cartilage, cricoid cartilage, cricothyroid membrane, ﬁrst and second tracheal rings, and sternal notch. The ideal insertion site for either technique is inferior to the ﬁrst or second tracheal ring. Tracheostomies placed in the cricothyroid membrane have a higher incidence of tracheal stenosis, and those placed more inferiorly than the third or fourth ring may have a higher incidence of tracheoinnominate ﬁstula formation.
With a surgical tracheostomy, the strap muscles are separated in the midline, exposing the isthmus of the thyroid gland. This usually overlies the second and third tracheal cartilaginous rings. If not retractable, the isthmus should be freed, divided, and ligated as illustrated. A Björk ﬂap, an inferiorly based inverted U-shaped ﬂap, is then created and sewn to the skin. A properly sized tracheostomy tube is then inserted and securely ﬁxed.
Percutaneous dilational tracheostomy uses the same anatomic landmarks. After a small skin incision is made, blunt dissection is performed to the level of the trachea. A guidewire is placed via the modiﬁed Seldinger technique under bronchoscopic visualization, and the tract is dilated, most commonly with a initial punch dilator and then a single tapered dilator. The tracheostomy tube is then inserted and secured.
The classic silver-plated Jackson tracheostomy tubes have been replaced over the past decade by a variety of nonirritating plastic tubes. These have large-volume, low-pressure cuffs similar to endotracheal tubes, allowing for mechanical ventilation with minimal injury to the tracheal mucosa. Nonetheless, as with endotracheal tubes, cuff pressures should be followed, and kept below 20 mm Hg.
Tracheostomy has several beneﬁts over translaryngeal intubation, including a requirement for less sedation, the ability to mobilize patients without fear of losing an airway, and perhaps more rapid weaning from mechanical ventilation and lower mortality rates.
One-way valves (Passy-Muir) offer the ability to speak to some patients and can be of great psychological comfort to patients and their families.
Damage to the trachea from tracheostomy tubes can occur at the top of the tube, at the stoma, or at the level of the inﬂatable cuff. Erosion may occur into the esophagus, particularly if prolonged use of a nasogastric tube is also necessary, or into a major vessel with usually fatal results.