What are the steps in an open tracheostomy procedure?

Open Tracheostomy Procedure Steps

Open tracheostomy should be performed following a systematic, stepwise approach with meticulous attention to pre-procedural preparation, patient positioning, anatomical landmarks, and post-insertion confirmation to minimize complications and ensure proper tube placement. 1

Pre-Procedural Preparation

Personnel and Equipment Assembly:

• Assemble a minimum team of two physicians (one surgeon and one managing anesthesia/ventilation) plus at least one paramedic assistant 2, 1
• Prepare all equipment and medications using a checklist before entering the room, including emergency airway equipment, suction apparatus, tracheostomy tubes (current size and one size smaller), ties, shoulder roll, and scissors 1, 3
• Avoid bringing carts into the room to reduce decontamination requirements 1, 3
• Perform universal protocol and time-out outside the room with the procedure team 1, 3
• Don enhanced PPE per institutional protocol (N95 respirator, face shield, gown, double gloves) before entering 1, 3

Pre-Procedural Assessment:

• Use ultrasound to assess neck anatomy, identify vascular structures (particularly the thyroid isthmus and anterior jugular veins), and determine the optimal incision point between the 2nd and 3rd tracheal rings 1, 3
• Perform a pre-procedural apnea test (withhold ventilation for 30-60 seconds with FiO₂ 100%) to confirm the patient can tolerate brief periods without ventilation during critical steps 2, 1

Patient Preparation and Anesthesia

Anesthetic Management:

• Administer deep sedation with neuromuscular blockade to minimize cough and agitation throughout the procedure 2, 1
• Ventilate in volume-controlled mode with FiO₂ = 100% 2, 3
• Monitor neuromuscular blockade continuously to ensure complete paralysis during tracheal manipulation 1, 3

Patient Positioning:

• Position the patient supine with neck hyperextended using a shoulder roll placed under the shoulders to bring the trachea anteriorly and make anatomical landmarks more prominent 2, 1, 3
• Prepare the surgical field with antiseptic (chlorhexidine or povidone-iodine) from chin to clavicles 1

Surgical Technique

Anatomical Identification:

• Palpate the cricoid cartilage as the primary anatomical landmark 1
• Identify the target site between the 2nd and 3rd tracheal rings, approximately 2-3 fingerbreadths below the cricoid cartilage 1
• This location is optimal because it avoids cricoid injury, minimizes risk of tracheo-innominate fistula, allows adequate tube length for secure positioning, and provides easier access for emergency tube replacement 1

Skin Incision and Dissection:

• Make a horizontal skin incision approximately 2-3 cm in length, midway between the cricoid cartilage and sternal notch 1
• Dissect through subcutaneous tissue and platysma muscle 3
• Separate the strap muscles (sternohyoid and sternothyroid) in the midline and retract laterally 1
• Identify and manage the thyroid isthmus by either retracting superiorly, dividing between clamps and ligating, or retracting inferiorly depending on anatomy 1

Tracheal Incision and Tube Insertion

Critical Airway Management Steps:

• Withdraw the endotracheal tube under direct visualization until the cuff is just below the glottis with the cuff inflated 2
• Pack the oropharynx and hypopharynx with gauze, and place a suction tip in the mouth to reduce aerosolization of oral secretions 2, 3
• Initiate apnea (withhold ventilation) immediately before making the tracheal incision 2, 1
• Make a vertical or horizontal incision in the anterior tracheal wall between the 2nd and 3rd tracheal rings during apnea 1, 3
• Avoid or minimize use of electrocautery and suction during tracheal opening as these increase aerosolization risk 2
• Place moist gauze around the neck stoma to capture aerosols 2, 3

Tube Insertion:

• Insert the tracheostomy tube in a downward, inward arc through the tracheal opening 1, 3
• Immediately remove the obturator after tube insertion 1, 3

Securing and Confirming Tube Placement

Immediate Post-Insertion Steps:

• Remove the shoulder roll to return the neck to neutral position 3
• Inflate the cuff to appropriate pressure (20-30 cmH₂O) 4
• Lock the inner cannula in place 3
• Secure the tracheostomy tube with ties tight enough to prevent dislodgement but loose enough to allow one finger to slip beneath 4, 3
• Resume ventilation and connect to the ventilator circuit 2, 1
• Remove the endotracheal tube from the oropharynx during apnea 2

Confirmation of Placement:

• Confirm adequate ventilation with waveform capnography 2, 1
• Perform clinical assessment including auscultation of bilateral breath sounds 2
• Consider fiberoptic bronchoscopy to verify proper tube position within the trachea 2
• Obtain chest X-ray to confirm tube position and rule out pneumothorax 1
• Document tube size, depth at the skin, and cuff pressure 1

Stoma Management:

• Place a petrolatum gauze dressing at the fresh stoma site to prevent aerosolization or air leak until the stoma heals 2, 3
• Keep the peristomal skin clean and dry to prevent infection and pressure necrosis 4

Post-Procedural Documentation

Essential Documentation:

• Write a detailed tracheostomy report including indication, technique used, tube type and size, depth of insertion, any complications encountered, and confirmation of placement 2
• Ensure bedside emergency equipment is immediately available including manual resuscitation bag, suction source, replacement tubes (same size and one size smaller), extra ties, shoulder roll, and scissors 4

Critical Safety Considerations

Key Apnea Intervals to Minimize Aerosol Generation: The most critical moments for maintaining apnea during open tracheostomy include: during pullback of the endotracheal tube with cuff deflation, during the anterior tracheal wall incision, during insertion of the tracheostomy tube, and during removal of the endotracheal tube from the oropharynx 2, 1. These intervals represent the highest risk for aerosol generation and potential pathogen transmission to healthcare workers.

Common Pitfalls to Avoid:

• Incising too high (through the cricoid cartilage) can cause subglottic stenosis 1
• Incising too low (below the 4th tracheal ring) increases risk of tracheo-innominate fistula 1
• Failing to maintain apnea during tracheal incision significantly increases aerosol generation 2
• Inadequate tube securing can lead to early accidental decannulation, which is life-threatening in the first 7 days before tract maturation 4