Tracheostomy
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Direct answer
Tracheostomy is the surgical opening of the trachea in the midline, at the level of the second and third tracheal rings, to establish a secure airway below the larynx. It is done as an emergency for upper airway obstruction or as an elective, planned procedure for prolonged ventilation and retained secretions. The thyroid isthmus, overlying the second to fourth rings, is displaced or divided, and complications are classified as immediate, intermediate or late — haemorrhage, tube blockage or displacement, and tracheal stenosis respectively.
What you must remember
- Emergency indications: any acute upper airway obstruction — unremovable foreign body, angioedema, laryngeal trauma, deep neck abscess, bilateral cord palsy and severe croup.
- Elective indications: prolonged intubation and ventilation, poor laryngeal protective reflexes with aspiration, retained secretions in neurological disease, obstructive sleep apnoea awaiting definitive surgery, and as access before major head and neck surgery.
- Procedure: transverse or vertical incision, separation of the strap muscles, displacement or division of the thyroid isthmus, midline incision of the trachea at the second and third rings, and tube insertion; in children a vertical incision and careful high placement matter.
- Immediate complications: haemorrhage, air embolism, apnoea from sudden fall in airway resistance, cardiac arrest, pneumothorax and subcutaneous emphysema, and injury to nearby structures including the recurrent laryngeal nerve.
- Intermediate complications: tube blockage by crusts, accidental decannulation with loss of the airway, local infection and tracheitis, tracheo-oesophageal fistula, and pressure necrosis.
- Late complications: tracheal stenosis at the stoma or cuff site, tracheocutaneous fistula, tracheoinnominate artery erosion, tracheomalacia and disfiguring scar.
- Aftercare and decannulation: humidification, regular suction and correct tube and cuff care; decannulation is gradual — occlude the tube for a day or two before removal once the indication has resolved, and let the stoma heal.
Common confusion
Tracheostomy is often confused with cricothyroidotomy, the rapid entry through the cricothyroid membrane for the dire emergency, to be converted later. Also, a displaced fresh tube cannot be blindly replaced because the track has not formed — hence stay sutures, secure tapes and delaying the first tube change.
Exam-focused takeaway
For theory, give a definition, grouped indications, the steps in one line each, and complications classified by time of onset — the classification carries the marks. In viva, expect the level of the tracheal opening, the structure crossed (thyroid isthmus), the danger in children and the steps of safe decannulation. In the posting, learn suction and humidification hands-on, and counsel a tracheostomy patient — practical skills examiners observe directly.
Frequently asked questions
At which rings is tracheostomy performed?
Through an opening at the second and third tracheal rings, below the cricoid, displacing or dividing the thyroid isthmus that overlies the second to fourth rings.
How are complications classified?
As immediate (haemorrhage, pneumothorax, subcutaneous emphysema, apnoea), intermediate (tube blockage, displacement, infection, fistula) and late (tracheal stenosis, tracheocutaneous fistula, artery erosion).
What are the elective indications?
Prolonged intubation or ventilation, inability to protect or clear the airway in neurological disease, and planned airway control before major head and neck surgery.
Why is the paediatric tracheostomy riskier?
The child's trachea is small, soft and mobile with a high-lying innominate artery and shallow landmarks, so a vertical tracheal incision and meticulous placement are essential to avoid stenosis and vessel injury.
How is decannulation performed?
By staged occlusion of the tube for a day or two with monitoring, followed by removal once breathing and secretion clearance are adequate, and dressing of the stoma to heal.
What is a tracheoinnominate fistula?
Erosion of the innominate artery by the tube tip or cuff, presenting as a sentinel bleed followed by massive haemorrhage — a rare but lethal late complication.