How to Insert a Tracheostomy Tube

Inserting a tracheostomy tube involves creating a small opening in the front of the neck, through the trachea (windpipe), and placing a curved tube through that opening to establish a direct airway. The procedure is performed either as a traditional open surgery with a scalpel or as a less invasive percutaneous technique using a needle and dilator, both under controlled conditions with the patient sedated or under general anesthesia. While the basic concept is straightforward, the details of how clinicians prepare, choose their approach, avoid blood vessels, select the right tube, and manage the airway afterward are where the real complexity lives.

Why a Tracheostomy Is Performed

The most common reason for a tracheostomy is prolonged mechanical ventilation. When a patient in an intensive care unit has been breathing through a tube placed down the throat (an endotracheal tube) for an extended period, that tube starts causing problems: it can damage the vocal cords and larynx, it makes weaning from the ventilator harder, and it limits the patient’s ability to communicate or eat. A tracheostomy bypasses the upper airway entirely, sitting lower in the neck and leaving the mouth and throat free.

Other reasons include upper airway obstruction from tumors, trauma, or severe swelling; neuromuscular diseases that weaken the muscles of breathing; and the need for long-term airway access in patients who cannot protect their own airway from secretions. In children, the indications shift somewhat toward congenital airway abnormalities and conditions requiring prolonged ventilatory support.

When to Do It

Timing remains one of the more debated questions in critical care. Most definitions consider a tracheostomy “early” if it happens within seven to ten days of intubation, and “late” if it happens after that window. A Cochrane review of seven randomized trials found that early tracheostomy was associated with lower mortality compared to late tracheostomy, and patients in the early group were more likely to be discharged from the ICU by day 28.¹ However, a separate large analysis reached a more cautious conclusion, finding that early tracheostomy was not clearly associated with lower ICU mortality but might reduce pneumonia rates, which could challenge the common practice of waiting beyond the first week.² The practical upshot is that clinicians weigh each patient’s trajectory individually rather than following a rigid calendar.

Anatomy and Patient Preparation

The target site sits between two landmarks you can feel on the front of your neck: the cricoid cartilage (the firm ring at the bottom of the larynx) and the sternal notch (the dip at the top of the breastbone). An ideal tracheostomy opening is placed between these two points, typically through the space between the second and third tracheal rings. The incision is often described as being one to two fingerbreadths above the sternal notch.³

The patient lies on their back with their neck extended, usually by placing a roll under the shoulders. This position pushes the trachea forward and stretches the skin, making the landmarks easier to feel and the airway more accessible. Before any cutting or needle insertion, the team confirms the landmarks by palpating the midline cartilage structures. In heavier patients or those with short necks, these landmarks can be difficult to feel, which is one reason ultrasound has become increasingly popular for pre-procedure mapping.

Ultrasound can identify the tracheal rings, the cricoid cartilage, and the spaces between rings, even in patients whose anatomy is hard to palpate. In one randomized trial comparing the conventional landmark-based method to an ultrasound-guided approach, the ultrasound group benefited from clear visualization of the cricoid cartilage and the space between tracheal rings before any puncture was made.⁴ Pre-procedure ultrasound also reveals blood vessels running across the intended path, allowing the operator to adjust their entry point.

The Open Surgical Approach

Open (or “surgical”) tracheostomy is the older and more traditional method, performed in an operating room or at the bedside. After marking the skin and injecting local anesthetic, the surgeon makes a horizontal or vertical skin incision. The tissue layers beneath the skin are separated in the midline, moving aside the strap muscles that run along each side of the trachea and, if present, the thyroid isthmus (a thin bridge of thyroid tissue that sometimes crosses the operative field).

Once the front wall of the trachea is exposed, the surgeon creates an opening. There are different ways to do this. A straightforward vertical cut through two tracheal rings is one option. Another is creating a small flap, often called a Björk flap, where the surgeon cuts a U-shaped piece of tracheal wall and stitches it down to the skin of the neck. This flap creates a more stable opening and makes it much easier to reinsert the tube if it accidentally falls out in the early days after surgery. One institutional study found that accidental decannulation occurred in fewer than one in 300 patients when a Björk flap was used, compared to roughly one in 20 patients who had a conventional vertical incision.⁵

With the tracheal opening made, the endotracheal tube that has been keeping the patient breathing is pulled back just enough so the tracheostomy tube can be inserted under direct vision. The tube is gently advanced through the stoma and into the trachea, the inner cuff is inflated to seal against the tracheal wall, and the ventilator circuit is connected to the new tube. Correct placement is confirmed by listening for breath sounds, watching for carbon dioxide on the monitor, and sometimes with a bronchoscope passed through the new tube.

The Percutaneous Approach

Percutaneous dilatational tracheostomy, developed in the 1980s and refined since, takes a less invasive path to the same destination. Instead of dissecting down through tissue layers with a scalpel, the operator makes a small skin nick, inserts a needle into the trachea, passes a guidewire through the needle, and then dilates the tract over the wire until it is wide enough to accept the tracheostomy tube. Think of it as similar in concept to how an interventional cardiologist accesses a blood vessel, except the target is the airway.

During the procedure, a bronchoscope is often passed through the existing endotracheal tube so the operator can watch the needle enter the trachea from the inside, confirming that the puncture is in the right spot and that the back wall of the trachea is not being injured.⁶ The endotracheal tube is withdrawn just above the puncture site but left in place as a safety backup until the tracheostomy tube is secured and ventilation confirmed.

The percutaneous method has become the dominant approach in many ICUs because it can be done at the bedside without transporting a critically ill patient to the operating room. It requires less dissection and generally takes less time than an open procedure.

How the Two Techniques Compare

From a safety standpoint, both approaches have similar overall complication profiles, with one notable exception: wound infection around the stoma is consistently less common after percutaneous tracheostomy. A systematic review and meta-analysis found the odds of wound infection were roughly 70% lower with the percutaneous method compared to open surgery.⁷ A separate study comparing the two in ICU patients confirmed that the rate of infection around the stoma was higher with the open approach, with no significant difference in other complications between the groups.⁸ The likely reason is that the percutaneous technique creates a tighter wound with less exposed tissue.

That said, open surgery has clear advantages in certain situations. When the anatomy is distorted by previous neck surgery, radiation therapy, large goiters, or dense scar tissue, the ability to see and work around abnormal structures is safer than blindly dilating a tract. The open approach also remains standard for most pediatric tracheostomies, where the small size and softness of a child’s trachea make the percutaneous method riskier.

Real-Time Ultrasound During the Procedure

Beyond the pre-procedure scan described earlier, some centers now use ultrasound in real time as the needle is being inserted. This allows the operator to watch the needle tip enter the trachea, confirm midline placement, and avoid vessels at the moment of puncture rather than relying on a mental map from a scan done minutes before. A propensity-matched analysis found that real-time ultrasound guidance during percutaneous tracheostomy dramatically reduced complications: the odds of an adverse event were about 92% lower compared to the standard approach without ultrasound.⁹

One common concern is what to do when the pre-procedure ultrasound reveals a blood vessel crossing the intended puncture site. In practice, these are almost always small veins rather than arteries. A study examining this question found that veins measuring about 4 millimeters or smaller at the access site did not increase bleeding risk during percutaneous tracheostomy, suggesting that their presence alone should not automatically force a switch to an open surgical approach.¹⁰

Choosing the Right Tube

Tracheostomy tubes come in a surprising variety of shapes, sizes, and features, and the choice matters more than many people realize. The key dimensions are the inner diameter (how wide the breathing channel is), the outer diameter (how much space the tube takes up in the trachea), and the length and curvature of the tube. Here is where it gets tricky: two tubes from different manufacturers with the same listed inner diameter can differ in outer diameter, length, and curvature, which means swapping brands is not always straightforward.¹¹

Tubes can be cuffed or uncuffed. A cuffed tube has a small balloon near the tip that, when inflated, seals the trachea and prevents air from leaking around the tube. This is essential for patients on mechanical ventilation, where a sealed system is needed to deliver breaths effectively. Uncuffed tubes are used when the patient no longer needs positive-pressure ventilation but still needs the tracheostomy for airway protection or secretion management. Some tubes are fenestrated, meaning they have small holes in the outer curve that allow air to pass upward through the vocal cords, enabling the patient to speak when the tube opening is capped. Others include a removable inner cannula that can be pulled out and cleaned without removing the entire tube from the trachea.

Getting the fit right is important. A tube that is too short may not sit securely in the trachea, risking displacement. One that is too long can irritate the back wall of the trachea or even push against the carina (the point where the trachea splits into the two main bronchi), causing coughing and discomfort. Obese patients often need extended-length or adjustable-flange tubes because the distance from the skin surface to the trachea is greater.

What Can Go Wrong

Complications fall into two time frames: those that happen during or immediately after the procedure, and those that develop over weeks or months. Immediate complications include bleeding (usually from small veins in the thyroid or pretracheal tissue), injury to the back wall of the trachea, pneumothorax (air leaking into the chest cavity), and subcutaneous emphysema (air tracking under the skin around the neck).¹² Tube displacement in the first few days, before a mature tract has formed, is among the most dangerous complications because the stoma can close rapidly, leaving the patient without an airway.

Late complications include tracheal stenosis, where scar tissue narrows the trachea after the tube is removed. In one study of trauma patients, tracheal stenosis occurred at similar rates regardless of whether the tracheostomy was percutaneous or open, affecting roughly 1 to 2 percent of patients. Those who developed stenosis tended to be younger and had spent longer in the ICU.¹³ Other late problems include tracheomalacia (softening of the tracheal cartilage), granuloma formation at the stoma site, and, rarely, a fistula between the trachea and the innominate artery or esophagus.

Care After the Tube Is In

Once the tube is in place, routine care centers on keeping the airway clear and the stoma clean. Suctioning removes secretions that the patient cannot cough out effectively, and the frequency depends on how much secretion the patient produces. Humidification of inspired air becomes critical because the tracheostomy bypasses the nose and mouth, which normally warm and moisten incoming air. Without humidification, secretions dry out and can form crusts that block the tube.

A systematic review of humidification options found that heated humidifiers consistently delivered the highest moisture levels and were most effective at reducing respiratory complications and keeping patients comfortable. Heat-and-moisture exchangers (small passive devices that sit on the tube connector) are convenient and portable but struggle to provide adequate humidity, especially when supplemental oxygen is being delivered.¹⁴

Stoma care involves regular cleaning of the skin around the tube, inspecting for signs of infection or skin breakdown, changing the dressing, and checking the tube ties or holder that keep the tube secured. If the tube has an inner cannula, that component is typically removed and cleaned or replaced at regular intervals throughout the day. The first tube change, meaning removing the original tube and placing a new one, is usually not attempted until the tract has had time to mature, often around five to seven days after insertion, though the timing varies by institutional protocol.

Accidental Dislodgement

A tracheostomy tube falling out or being pulled out accidentally is a genuine emergency, particularly in the first week before the tract is well established. Hospitals address this risk through standardized emergency kits kept at the bedside and communication tools posted in the patient’s room that alert any responding clinician to the presence of the tracheostomy and its specifications. One hospital-based quality improvement project that implemented an evidence-based “dislodgement bundle” achieved 100% adherence with keeping an emergency tracheostomy kit and communication tool at the bedside, though adherence to using the formal algorithm during actual events was lower.¹⁵ The Björk flap technique mentioned earlier was specifically developed to reduce the danger of accidental decannulation by creating a tract that stays open and is easier to recannulate.

Patients Who Make the Procedure Harder

Certain patient groups carry higher procedural risk and may require modified approaches. The most commonly encountered risk factors are bleeding disorders and morbid obesity. A systematic review covering over 2,200 patients with conditions traditionally considered contraindications to percutaneous tracheostomy found that bleeding diathesis accounted for about 42% of cases and morbid obesity for about 16%.¹⁶ In experienced hands, many of these patients can still undergo percutaneous tracheostomy safely, though the procedure demands more preparation and often involves ultrasound guidance.

Patients with previous neck surgery, radiation-induced scarring, or goiters present a different challenge. Scar tissue distorts normal tissue planes, making it hard to predict where blood vessels are and how the trachea lies relative to surrounding structures. A case series of critically ill patients with prior neck surgery demonstrated that a minimally invasive tracheostomy approach could be performed without complications in these high-risk patients, including two with morbid obesity and five with cutaneous or tracheal scarring.¹⁷ Still, guidelines consistently advise caution in patients with previous neck surgery, radiation therapy, or unclear surgical anatomy.¹⁸

Tracheostomy in Children

Pediatric tracheostomy is relatively uncommon, performed in roughly 0.2% of inpatient stays at tertiary pediatric hospitals. But when it is needed, the stakes are high: mortality in children with tracheostomies ranges from 10 to 20%, largely because the children who need them tend to have serious underlying conditions.¹⁹ The procedure itself differs in several respects from the adult version. A child’s trachea is smaller, softer, and more mobile, making it easier to inadvertently push the tube through the back wall. The open surgical technique is standard in children, with the percutaneous approach generally avoided in younger patients. Tube sizing is more delicate, and because children grow, the tube may need to be upsized over time. Caregiver education takes on outsize importance as well, since many children with tracheostomies are eventually discharged home, and their parents or guardians become the primary managers of airway care.

The Decision-Making Process

For families, the decision to proceed with a tracheostomy can be agonizing. It often comes at a time when a loved one has been critically ill for days or weeks, and the conversation about tracheostomy signals that recovery may be slow and the road ahead long. A study examining decisional needs in adults facing tracheostomy and prolonged mechanical ventilation found that surrogates and families needed information about the patient’s wishes, their baseline activity level before illness, realistic short- and long-term outcomes, and what “meaningful recovery” would look like. The decision-making process sat at a balance point between the surrogate’s emotions and the physician’s medical recommendations.²⁰

In pediatrics, decision support tools have been developed to help parents navigate this territory. A video-based decision aid tested with parents of children facing tracheostomy was described as empowering, helping parents feel less isolated and more prepared to ask questions and voice their concerns to the medical team.²¹ These tools do not replace the clinical conversation, but they fill a gap that a single bedside discussion often cannot cover, especially when the family is processing the emotional weight of the situation at the same time they are trying to absorb medical information.