Tracheostomy Insertion at C2-C3 (Second and Third Tracheal Rings)
Tracheostomy insertion between the second and third tracheal rings (C2-C3) is the standard recommended site because it provides optimal anatomical positioning that balances accessibility, safety, and minimizes both early and late complications, though this location does not eliminate all risks.
Anatomical Rationale
The C2-C3 location is recommended based on several anatomical considerations:
- Optimal accessibility: The second and third tracheal rings provide a consistent, palpable landmark that is reliably accessible through standard surgical approaches 1
- Avoidance of cricoid cartilage: Placement below the first tracheal ring avoids injury to the cricoid cartilage and subglottic region, which would increase risk of subglottic stenosis 2
- Standardized technique: The French Society of Anaesthesia and Intensive Care Medicine specifically recommends that "the point of incision should ideally be between the 1st and 2nd tracheal rings" 1, though C2-C3 remains the most commonly practiced standard
Technical Advantages
Bronchoscopic guidance at the C2-C3 level facilitates safe placement by allowing direct visualization of the puncture site, proper dilator positioning, and final tube placement, which reduces complications like pneumothorax, subcutaneous emphysema, and paratracheal false passage 3
- The C2-C3 location allows for transillumination techniques to confirm proper positioning before tracheal entry 1, 3
- This site provides adequate space for tube insertion while maintaining sufficient distance from critical structures 3
Important Caveats and Limitations
Innominate Artery Risk
A critical anatomical reality is that C2-C3 placement does NOT guarantee protection from innominate artery injury, contrary to classical teaching 4
- Cadaveric studies demonstrate that in every dissection, some part of the tracheostomy tube cuff or tip was adjacent to the innominate artery when placed at C2-C3 4
- Blood in tracheal secretions may precede catastrophic hemorrhage and requires immediate evaluation 5
- Tracheoinnominate fistula remains a potential late complication regardless of C2-C3 placement 2
Alternative Access Points
In specific clinical scenarios, alternative sites may be necessary:
- Trans-tracheal oxygen catheters are inserted percutaneously between the second and third tracheal rings for oxygen delivery, demonstrating this location's utility for minimally invasive access 1
- Emergency front-of-neck access: When cricothyroidotomy is impossible (e.g., after cricothyroid approximation surgery), percutaneous access between C2-C3 may be the only option 1
Procedure-Specific Considerations
Percutaneous Technique
- Modified Ciaglia technique introduces tubes (#6-10) between the second and third tracheal rings under bronchoscopic guidance 3
- Ultrasound identification of vasculature before puncture at C2-C3 is recommended to enhance safety 5
Surgical Technique
- The endotracheal tube should be advanced distal to the C2-C3 operative site before opening the trachea 5
- Hyperextension of the neck with a pillow under the shoulders brings the trachea anteriorly, facilitating C2-C3 access 1
Complication Profile at C2-C3
Early complications at this site include:
- Bleeding (controllable with local pressure in most cases) 3
- Pneumothorax (rare with proper technique) 3
- Subcutaneous emphysema (if false passage created) 3
Late complications include:
- Tracheal stenosis 2
- Tracheomalacia 5, 2
- Tracheoesophageal fistula 2
- Tracheoinnominate fistula (despite C2-C3 placement) 4
Clinical Bottom Line
The C2-C3 location represents a compromise between competing anatomical constraints rather than an ideal site that eliminates all risks. Operator experience, bronchoscopic guidance, ultrasound vascular mapping, and individualized assessment of neck anatomy are more important than rigid adherence to C2-C3 placement alone 3, 6. The site should be confirmed by palpation, transillumination, and when available, ultrasound before incision 1.