Tracheostomy and Airway Management
On this page
Direct answer
Tracheostomy is a surgical opening into the trachea, usually through the second to fourth tracheal rings, used to bypass upper airway obstruction or to secure a route for prolonged ventilation. Its main indications are upper airway obstruction, prolonged mechanical ventilation, failed extubation and impaired airway protection. Elective tracheostomy is a planned procedure, whereas cricothyroidotomy is reserved for the rescue scenario in which the airway can be neither intubated nor oxygenated.
What you must remember
- Indications: upper airway obstruction from tumour or oedema, prolonged ventilation, weak airway protection and the need for pulmonary toilet.
- Techniques: surgical tracheostomy suits obstruction and difficult anatomy, while percutaneous dilatational tracheostomy is common in stable intensive care patients.
- Early complications: bleeding, pneumothorax, subcutaneous emphysema, false passage and tube displacement.
- Serious bleeding: haemorrhage from the thyroid isthmus or innominate artery needs urgent assessment, and a tracheo-innominate fistula is a catastrophic late event.
- Late complications: tracheal stenosis, tracheomalacia, granulation tissue and infection, which develop over weeks to months.
- Cuff management: cuff pressure is checked regularly and kept within the safe range, usually around 20 to 30 cm H2O.
- Speaking valves: they are used only when the cuff is deflated and the upper airway is patent and safe, under supervision.
A decision pathway for technique and aftercare
A 70-year-old woman with a large oropharyngeal tumour now has stridor and is struggling to swallow her secretions. The airway must be secured with a plan that allows safe ventilation, suction and later decannulation. Each step below depends on the one before it.
- Define the indication: upper airway obstruction, prolonged ventilation or weak airway protection each justifies tracheostomy, and the goal is set before the procedure.
- Choose the route: surgical tracheostomy suits obstruction and difficult anatomy, whereas percutaneous dilatational tracheostomy suits stable patients with favourable anatomy and bronchoscopic guidance.
- Secure the site: identify landmarks, avoid the thyroid isthmus and keep the tube in a neutral position, with a spare tube of the same size and one size smaller at the bedside.
- Watch the early days: monitor for bleeding, subcutaneous emphysema, pneumothorax and tube displacement, since the tract is not yet mature.
- Maintain the tube: humidify the airway, suction as needed, check cuff pressure and change inner cannulas according to the unit protocol.
- Plan decannulation: once the cause has resolved, test with a speaking valve and cuff deflation, and confirm the upper airway is patent before removing the tube.
Where the exam tries to catch you
Most tracheostomy questions test the difference between planned and emergency airway access, and between early and late complications.
- Trap: using cricothyroidotomy as the first choice for an elective airway Correct: elective tracheostomy is planned, whereas cricothyroidotomy is the rescue for cannot intubate, cannot oxygenate.
- Trap: deflating the cuff permanently to protect the trachea Correct: cuff pressure must be monitored, and deflation is allowed only for speaking or weaning under supervision.
- Trap: assuming tracheal stenosis is an early problem Correct: stenosis develops over weeks to months, while bleeding and displacement are the early hazards.
- Trap: treating a tracheostomy bleed with packing alone Correct: significant bleeding needs urgent bronchoscopy and surgical control, because an innominate artery bleed is catastrophic.
Frequently asked questions
What are the main indications for tracheostomy?
The main indications are upper airway obstruction, prolonged mechanical ventilation, failed extubation and impaired airway protection with poor secretion clearance. Tracheostomy also facilitates pulmonary toilet and allows the patient to be weaned from ventilation more easily.
Which early complications occur after tracheostomy?
Early complications of tracheostomy include bleeding, pneumothorax, subcutaneous emphysema, false passage creation and tube displacement. Most early complications are preventable with careful landmarking and bedside monitoring.
What is the cannot intubate, cannot oxygenate rule in airway management?
Cannot intubate, cannot oxygenate is a failed airway situation in which neither intubation nor oxygenation by face mask succeeds. It calls for immediate front-of-neck access, which in adults is cricothyroidotomy using a scalpel, bougie and tube technique.
Why is cuff pressure monitored in a tracheostomy tube?
Cuff pressure is monitored because excessive pressure damages the tracheal mucosa and can cause ischaemia, while low pressure allows aspiration. Regular checks keep the cuff within the safe range, usually around 20 to 30 cm H2O.
How is a speaking valve used with a tracheostomy?
A speaking valve allows air to pass through the upper airway so the patient can phonate, but only when the cuff is deflated and the airway is patent and safe. It is introduced under supervision, with monitoring for aspiration and breathlessness.