Tracheostomy — Procedure Guide, Recovery & Risks | MyMedicPlus

Tracheostomy is a surgical procedure that creates a direct opening through the anterior neck into the trachea, bypassing the upper airway to provide a secure and reliable airway. A tracheostomy tube is inserted through this stoma and can be connected to a mechanical ventilator or left open to allow spontaneous breathing with humidified air. Two principal techniques exist: open surgical tracheostomy performed in the operating theatre under general anaesthesia through a horizontal or vertical cervical incision, and percutaneous dilational tracheostomy (PDT) performed at the intensive care unit bedside under sedation and local anaesthesia using the Seldinger wire-guided technique with real-time fibreoptic bronchoscopic visualisation. Tracheostomy offers major advantages over prolonged translaryngeal intubation by reducing sedation requirements, decreasing anatomical dead space by up to 150 mL, lowering airway resistance, improving secretion clearance by suction, facilitating ventilator weaning, enabling early oral feeding and speech via speaking valves, and improving overall patient comfort and rehabilitation. It is one of the most commonly performed bedside procedures in the ICU setting. Post-tracheostomy care is a multidisciplinary responsibility involving intensivists, specialist nurses, speech and language therapists, and respiratory physiotherapists working in coordinated teams to ensure safe tube management, optimise communication, and facilitate ventilator weaning and eventual decannulation.

Tracheostomy is indicated in several clinical scenarios. The most common ICU indication is prolonged mechanical ventilation anticipated to exceed 7-14 days, where early tracheostomy (within 7 days of intubation) reduces sedation use and ICU length of stay in appropriately selected patients. Upper airway obstruction from laryngeal cancer, bilateral vocal cord paralysis, traumatic laryngeal injury, severe post-extubation subglottic stenosis, or angioedema unresponsive to medical treatment may necessitate emergency or elective tracheostomy. Patients with impaired airway protective reflexes or inability to manage secretions due to bulbar palsy, motor neurone disease, Guillain-Barre syndrome, or high cervical spinal cord injury benefit from a tracheostomy for long-term secretion management. Planned elective tracheostomy is performed before major head and neck surgery such as total laryngectomy or glossectomy where post-operative airway oedema is anticipated.

For open surgical tracheostomy: the patient is positioned supine with the neck hyperextended using a shoulder roll. After skin preparation and sterile draping, a transverse or vertical midline incision is made midway between the sternal notch and the cricoid cartilage. The platysma is divided and the strap muscles separated in the midline. The thyroid isthmus is divided and the trachea exposed. A tracheal window or Bjork flap is created between the second and third tracheal rings (never through the first ring to avoid subglottic stenosis). The cuffed tracheostomy tube is inserted, cuff inflated, and correct placement confirmed by capnography, chest auscultation, and visualisation of tube misting. For percutaneous dilational tracheostomy (PDT): with a bronchoscope positioned in the airway, the trachea between rings 1-2 or 2-3 is punctured with an 18-gauge needle under direct bronchoscopic visualisation. A J-tip guidewire is introduced; a series of progressive dilators or a single Ciaglia Blue Rhino tapered dilator expands the tract; the tracheostomy tube is advanced over the dilator into position. Cuff inflation, capnography, and bronchoscopic confirmation complete the procedure. Total procedure time is 15-45 minutes for either technique. Post-procedure, correct positioning is confirmed by capnography waveform, chest auscultation for bilateral equal breath sounds, and bronchoscopic visualisation of the carina through the tracheostomy tube confirming intratracheal placement before ventilator circuit connection.

Tracheostomy provides several measurable clinical benefits over continued translaryngeal intubation. Percutaneous dilational tracheostomy performed under bronchoscopic guidance achieves an equivalent safety profile to open surgical tracheostomy in ICU patients, with lower rates of wound infection (2% vs 5-7%), lower cost, faster procedure time, and no requirement for operating theatre transfer. Early tracheostomy in selected mechanically ventilated patients has been associated with reduced duration of mechanical ventilation, shorter ICU stay, and lower sedation requirements in multiple randomised trials, though patient selection is critical. Speaking valves (Passy-Muir) allow voicing by permitting airflow through the larynx during exhalation, dramatically improving patient communication, wellbeing, and participation in rehabilitation. Decannulation is successfully achieved in the majority of ICU survivors once they meet established criteria: adequate spontaneous breathing, effective cough, manageable secretions, and safe swallowing function confirmed by speech and language therapy assessment.

Early complications of tracheostomy include intraoperative haemorrhage from anterior jugular veins or thyroid vessels (2-5%), inadvertent paratracheal tube placement in the pretracheal space, pneumothorax or pneumomediastinum from air tracking (under 1%), and hypoxia during tube exchange. Tube displacement — particularly dangerous in the first 5-7 days before the tract has fully matured — can result in rapid airway loss and must be treated as an emergency. Late complications include tracheal stenosis at the stoma or balloon cuff site (1-2%), the most common long-term complication, caused by mucosal ischaemia from over-inflated cuffs; regular cuff pressure monitoring (target under 25 cmH2O using a manometer) is mandatory. Tracheomalacia arises from prolonged cuff-induced cartilage damage. Stomal infection and granuloma formation cause localised morbidity. Tracheo-innominate artery fistula is rare (0.1-1%) but catastrophically life-threatening, typically presenting 3-6 weeks post-insertion with a sentinel bleed; it requires emergency surgical management. Swallowing dysfunction affects up to 50% of tracheostomised ICU patients and requires formal speech and language therapy assessment.

Tracheostomy tube care requires a structured daily protocol. Endotracheal suctioning using strict aseptic technique removes secretions; suctioning depth, frequency, and catheter size must be matched to the patient's secretion burden. Inspired gas must be humidified at all times using a heat-moisture exchanger (HME) or active heated humidifier to prevent secretion encrustation and tube blockage. The stoma skin is cleaned twice daily with saline-soaked gauze, dried carefully, and a split tracheostomy dressing applied. Tube holder or ties are checked for correct fit — two-finger breadth between tie and neck. The first tracheostomy tube change is performed at 5-7 days by an experienced practitioner when the tract is mature; subsequent changes every 2-4 weeks maintain hygiene and prevent crusting. Decannulation proceeds through a structured protocol: tube downsizing to a smaller-diameter uncuffed tube, capping trials (occluding the tube to force airflow through the larynx for progressively longer periods), and formal assessment of cough strength, secretion management, and swallowing safety. Families and community nurses receive structured training before discharge where home tracheostomy is required.