What are the steps for performing an open tracheostomy?

Open Tracheostomy Procedure Steps

Open surgical tracheostomy should be performed using a systematic approach with meticulous attention to pre-procedural preparation, patient positioning, anatomical landmarks, and specific modifications to minimize aerosol generation and complications.

Pre-Procedural Preparation

Equipment and team assembly are critical first steps that directly impact procedural safety and outcomes. 1

• Assemble all equipment and medications using a checklist and procedure kits before entering the room to minimize contamination risk and procedural delays 2, 1
• Avoid bringing carts into the room to reduce decontamination needs 2, 1
• Ensure minimum team composition: two physicians (one operator, one managing sedation/ventilation/endotracheal tube) and at least one paramedic assistant 1
• Perform universal protocol and time-out outside the room with the procedure team 2, 1
• Don enhanced PPE per institutional protocol before entering (N95 respirator, face shield, gown, double gloves) 2, 1

Use ultrasound pre-procedurally to assess neck anatomy, identify vascular structures (particularly the innominate artery), and determine the optimal point of entry between the 2nd and 3rd tracheal rings 2, 1, 3

Patient Preparation and Anesthesia

Deep sedation with neuromuscular blockade is mandatory to minimize cough and agitation throughout the procedure 2, 1

• Administer general anesthesia with neuromuscular blockade and monitor blockade continuously 1
• Intubate and ventilate in volume-controlled mode with FiO₂ = 100% 1
• Perform a pre-procedural apnea test (withhold ventilation for 30-60 seconds after discontinuing PEEP and increasing FiO₂) to assess physiological stability before proceeding 2, 1
• If apnea is not tolerated, reduce ventilatory pressures and respiratory frequency to minimize aerosolization risk, or consider deferring the procedure 2

Patient Positioning

Position the patient with neck hyperextended using a shoulder roll to bring the trachea anteriorly and make anatomical landmarks more prominent 1

Prepare the surgical field with antiseptic (chlorhexidine or povidone-iodine) from chin to clavicles 1

Surgical Technique: Step-by-Step

Step 1: Identify Anatomical Landmarks

Palpate the cricoid cartilage as the primary anatomical landmark 1

• The cricoid is the only complete cartilaginous ring and must be preserved 3
• Identify the target site between the 2nd and 3rd tracheal rings (approximately 2-3 fingerbreadths below the cricoid) 3

Common pitfall: Never place the tracheostomy through the 1st tracheal ring or cricothyroid membrane, as this guarantees subglottic stenosis and cricoid injury 3

Step 2: Skin Incision

Make a horizontal skin incision approximately 2-3 cm in length, midway between the cricoid cartilage and sternal notch 1, 4

• The horizontal incision provides better cosmetic results and follows natural skin tension lines 4
• Incise through skin and platysma muscle 1

Step 3: Dissection to Trachea

Dissect the strap muscles (sternohyoid and sternothyroid) in the midline and retract laterally 4

• Avoid excessive lateral dissection to minimize bleeding 5
• Identify and manage the thyroid isthmus: either retract superiorly, divide between clamps and ligate, or retract inferiorly depending on anatomy 1

Step 4: Pre-Tracheal Incision Airway Management

This is a critical aerosol-generating moment requiring specific precautions: 2, 1

• Advance the endotracheal tube distally to a position just above the planned tracheal incision site 1
• Hyperinflate the endotracheal tube cuff 1
• Pause ventilation completely (apnea) at the moment of tracheal incision 2, 1
• Pack the oropharynx and hypopharynx with gauze to reduce aerosolization risk 2
• Place a suction tip in the mouth to reduce aerosolization of oral secretions 2

Step 5: Tracheal Incision

Make the anterior tracheal wall incision during apnea between the 2nd and 3rd tracheal rings 2, 1, 3

• Use a horizontal incision or vertical incision depending on surgeon preference 4
• Avoid or minimize the use of electrocautery (diathermy) during this step as it aerosolizes particles 2
• The horizontal cut extends to the membranous portion of the trachea, and the cut ends remain open naturally due to tracheal elasticity 4

Common pitfall: Avoid creating a cartilage window or removing cartilage, especially in pediatric patients, as this creates a stenotic segment 3

Step 6: Tracheal Tube Insertion

Once the trachea is opened: 1

• Cover the operative site with moist gauze when ventilation needs to be resumed briefly 1
• Insert the tracheostomy tube in a downward, inward arc through the tracheal opening 6
• Immediately remove the obturator after tube insertion 1, 6
• The tube should extend at least 2 cm beyond the stoma and remain 1-2 cm above the carina 3

Step 7: Securing the Tube

Secure the tracheostomy tube immediately to prevent displacement: 6

• Remove the shoulder roll to reposition the patient to neutral position 1
• Inflate the cuff to appropriate pressure (20-30 cmH₂O) 6
• Lock the inner cannula in place 1
• Secure ties around the neck tight enough to prevent dislodgement but loose enough to allow one finger to slip beneath the tie 6

Step 8: Confirmation and Dressing

Confirm proper tube placement using waveform capnography (mandatory) and auscultation 2

Place a petrolatum gauze dressing at the fresh stoma site to prevent aerosolization or air leak until the stoma heals 2, 1

Common pitfall: Do not use petroleum-based ointments routinely on the peristomal skin as they are contraindicated 6

Post-Procedural Immediate Steps

• Connect to ventilator circuit and confirm adequate ventilation with capnography 2
• Obtain chest X-ray to confirm tube position and rule out pneumothorax 1
• Document tube size, depth, and cuff pressure 6

Critical Safety Intervals for Aerosol Minimization

Throughout the procedure, maintain apnea at these specific high-risk intervals: 2

• During pullback of the endotracheal tube with cuff deflation
• During the anterior tracheal wall incision
• During insertion of the tracheostomy tube
• During removal of the endotracheal tube from the oropharynx

Place moist gauze or sponge around the neck stoma as needed during these intervals to capture aerosols 2

Key Anatomical Considerations

The 2nd-3rd tracheal ring location is optimal because: 3

• It avoids injury to the cricoid cartilage (which would cause subglottic stenosis)
• It minimizes risk of tracheo-innominate fistula (which occurs with lower placement and has 10% mortality)
• It allows adequate tube length for secure positioning while maintaining safe distance from the carina
• It provides easier access for emergency tube replacement

Common pitfall: Placement below the 3rd ring increases risk of innominate artery erosion and makes tube positioning relative to the carina problematic 3