Surgery: Tracheostomy
High-Yield Surgical Technique & Management for Board Review
A tracheostomy is the creation of a surgical opening into the trachea below the level of the larynx. It is indicated for upper airway obstruction, prolonged mechanical ventilation, and pulmonary toilet (secretion clearance).
1. Surgical Landmarks & Technique
- Optimal Site: The 2nd and 3rd tracheal rings are the preferred sites for the stoma.
- Positioning: Neck in extension (using a shoulder roll) to bring the trachea closer to the surface.
- Key Anatomy: The thyroid isthmus usually overlies the 2nd–4th rings and may require division or retraction.
- Important Avoidance: Avoid the 1st ring (risk of subglottic stenosis) and the cricoid cartilage.
2. Complications (The “Must-Know”)
| Type | Examples |
|---|---|
| Immediate | Hemorrhage, pneumothorax, air embolism, tracheal injury. |
| Early (Days) | Tube displacement/blockage, surgical site infection. |
| Late | Tracheal stenosis, tracheoesophageal fistula, tracheocutaneous fistula. |
3. High-Yield Board Exam Facts
- Most Dreaded Complication: Tracheo-innominate artery fistula; a catastrophic, high-pressure arterial bleed requiring immediate pressure and emergent surgical intervention.
- Stenosis Risk: High-pressure, low-volume cuffs are the leading cause of tracheal ischemia and subsequent stenosis. Modern tubes use low-pressure, high-volume cuffs.
- Tracheostomy vs. Cricothyroidotomy: Cricothyroidotomy is an emergency, temporary airway; tracheostomy is the preferred method for long-term airway management.
- Decannulation: Always verify the patient can tolerate a capped tube (upper airway patency) before permanent removal.