A tracheostomy is a procedure that creates a surgical opening, known as a stoma, through the neck and directly into the trachea, or windpipe. This opening is fitted with a tracheostomy tube, which establishes an alternative airway to help a person breathe, bypassing the nose, mouth, and upper throat. The purpose of this intervention is to secure a clear passage for air to reach the lungs when the normal upper airway is blocked or compromised. Inserting a tracheostomy tube is a complex, high-risk surgical action that must only be performed by highly trained medical professionals, such as surgeons or intensivists, in a sterile healthcare environment.
Prerequisites and Patient Preparation
The decision to perform a tracheostomy is based on specific medical indications. These include the need for prolonged mechanical ventilation, typically when a patient requires ventilator support for more than one or two weeks. Other reasons involve bypassing an obstruction in the upper airway (such as from a tumor, trauma, or severe swelling) or allowing for the effective clearance of pulmonary secretions in patients who cannot cough adequately.
Thorough preparation begins with positioning the patient supine, lying on their back, with the neck extended. This extension is often achieved by placing a small rolled towel beneath the shoulders, which helps bring the trachea closer to the skin surface. The surgical site is then prepped and draped to establish a sterile field, minimizing infection risk.
Before the procedure, a comprehensive equipment checklist is verified to ensure all necessary tools are available. This includes tracheostomy tubes of various sizes, a scalpel, local anesthetic, specialized retractors, and a light source. A means of immediate ventilation, such as a manual resuscitation bag and an endotracheal tube, must be at the bedside to maintain oxygenation. The medical team typically includes the primary surgeon, an assistant, an anesthesiologist or intensivist, and a respiratory therapist.
The Step-by-Step Insertion Procedure
The procedure begins with the surgeon identifying precise anatomical landmarks on the neck to guide the incision. The landmarks are the cricoid cartilage (a firm ring) and the thyroid cartilage (Adam’s apple). The incision is typically made either transversely or vertically in the lower neck, generally between the cricoid cartilage and the suprasternal notch, corresponding to the second or third tracheal ring.
Once the skin incision is made, the surgeon dissects through the subcutaneous fat and the strap muscles to expose the front of the trachea. These muscles are separated and retracted, not cut, to reveal the thyroid isthmus, the part of the thyroid gland crossing the midline. Depending on the technique, the thyroid isthmus may be retracted upward or downward, or occasionally divided to improve exposure of the tracheal rings.
With the trachea exposed, a small opening is created in the windpipe. This may involve removing a small piece of cartilage to create a tracheal window or puncturing the membrane between the tracheal rings. The patient’s existing airway, often an endotracheal tube, is temporarily pulled back slightly to prevent damage. The tracheostomy tube, pre-loaded with a guiding rod called an obturator, is then advanced through the stoma into the trachea.
As soon as the tube is confirmed to be inside the windpipe, the obturator is immediately removed. The cuff at the tip of the tube is then inflated with air. This inflation seals the space between the tube and the tracheal wall, allowing for positive pressure ventilation and protecting the lower airway from secretions. The ventilation circuit is connected to the tracheostomy tube, and controlled breaths are delivered to ensure air exchange.
Post-Placement Confirmation and Securing
Once the tracheostomy tube is positioned, the next steps focus on verifying correct placement and securing it to prevent dislodgement. Initial confirmation is performed by manually ventilating the patient and observing bilateral chest rise, indicating air is entering both lungs. This is supplemented by auscultation (listening with a stethoscope over both lung fields) to confirm audible breath sounds.
A more precise verification method involves using end-tidal carbon dioxide (EtCO2) monitoring, which measures the concentration of carbon dioxide in the exhaled breath. A persistent EtCO2 waveform provides objective evidence that the tube is correctly seated within the airway. The depth of the tube is then measured and documented in the patient’s record, providing a baseline for subsequent checks.
To stabilize the tube, specialized tracheostomy ties (cloth or padded straps) are passed around the neck and fastened to the flanges of the tube. In some cases, sutures may be placed through the skin and tied around the flange to provide temporary stability, particularly during the first few days before the stoma tract matures. A sterile dressing is applied around the stoma site to absorb minor drainage and protect the wound.
Immediate and Acute Complications
The insertion of a tracheostomy tube carries several risks of immediate complications. Hemorrhage, or significant bleeding, is a common intraoperative issue because the neck contains numerous blood vessels, including the thyroid arteries and anterior jugular veins. This bleeding may require immediate intervention to control.
Another serious risk is the development of a pneumothorax (a collapsed lung), which occurs when air leaks from the trachea and accumulates between the lung and the chest wall. Injury to surrounding structures is also a concern, specifically the recurrent laryngeal nerve (which controls the vocal cords) and the esophagus. Laceration of the posterior tracheal wall can occur if the surgical instrument or tube is advanced too aggressively.
Acute tube dislodgement, or accidental decannulation, is a life-threatening complication most likely to occur in the first few days before the tract has matured. If the tube comes out early, the stoma can close rapidly, making reinsertion challenging and risking airway loss. Air can also become trapped under the skin around the neck, a condition called subcutaneous emphysema. While often harmless, this can signal a more serious perforation of the airway.