What are the steps to perform a surgical tracheostomy?

How to Perform Surgical Tracheostomy

Open surgical tracheostomy involves direct surgical dissection with specific steps to minimize complications and ensure proper airway access, performed under general anesthesia with neuromuscular blockade in a controlled setting. 1

Pre-Procedural Preparation

Equipment and Team Assembly:

• Assemble all equipment and medications using a checklist before entering the procedure room 1
• Ensure minimum team of two physicians (one operator, one managing sedation/ventilation/endotracheal tube) and at least one paramedic assistant 1
• Have complete tracheostomy kit at bedside including functional suctioning system, oxygen source, and manual resuscitation bag 2
• Use ultrasound pre-procedurally to assess neck anatomy, identify vascular structures, and determine optimal point of entry 1
• Perform universal protocol and time-out outside the room with the procedure team 1

Patient Preparation and Positioning

Anesthesia and Positioning:

• Administer general anesthesia with deep sedation and neuromuscular blockade to minimize cough and agitation 1
• Intubate and ventilate in volume-controlled mode with FiO₂ = 100% 1
• Monitor neuromuscular blockade continuously throughout the procedure 1
• Position patient supine with neck hyperextended using a shoulder roll 1
• Prepare surgical field with antiseptic 1
• Perform pre-procedural apnea test to assess physiological stability 1

Surgical Technique Steps

Anatomical Identification and Incision:

• Identify the cricothyroid membrane as the primary anatomical landmark 1
• Make a horizontal or vertical incision through the skin and platysma muscle 1
• Perform careful dissection to expose the trachea while preserving recurrent laryngeal nerves 3

Critical Airway Management During Tracheal Entry:

• Advance the existing endotracheal tube distal to the operative site before opening the trachea 1
• Hyperinflate the endotracheal tube cuff 1
• Pause ventilation completely at the moment of tracheal incision to minimize aerosol generation 1
• Make the anterior tracheal wall incision between the 1st and 2nd tracheal rings during apnea 1
• Cover the operative site with gauze when ventilation is resumed 1

Tracheostomy Tube Insertion:

• Insert the tracheostomy tube through the tracheal opening 1
• Remove the obturator immediately after tube insertion 1
• Secure the tube with ties to prevent displacement 1

Immediate Post-Insertion Steps

Securing and Confirming Placement:

• Reposition patient to neutral position by removing the shoulder roll 1
• Inflate the tracheostomy tube cuff 1
• Lock inner cannula in place 1
• Confirm proper placement and ventilation 1
• Place petrolatum gauze dressing at the fresh stoma site to prevent aerosolization or air leak until the stoma heals 1

Important Considerations

Indications for Surgical vs. Percutaneous Approach:

• Both open surgical tracheostomy (OST) and percutaneous dilational tracheostomy (PDT) are acceptable techniques 1, 4
• Open surgical procedures are preferred during high-risk situations including difficult anatomy, coagulopathy, or when percutaneous landmarks cannot be identified 1
• The choice depends on local experience and available resources, with operators performing only procedures with which they are familiar and competent 1, 4

Common Pitfalls to Avoid:

• Never create a cartilage window in pediatric cases; use vertical tracheotomy instead to avoid stenosis 3
• Ensure adequate neuromuscular blockade throughout to prevent coughing during tracheal entry 1
• Avoid premature deflation of the endotracheal tube cuff before the tracheostomy tube is secured 1
• Do not resume ventilation until the operative site is covered with gauze to minimize aerosol generation 1

Timing Considerations:

• Tracheostomy should be considered when airway patency may be compromised for a considerable period or when prolonged mechanical ventilation (>10-14 days) is anticipated 5, 6
• The decision is informed by extent of airway compromise, likelihood of postoperative deterioration, ability to rescue the airway, and expected duration of significant airway compromise 5