What is the most common site for performing a tracheostomy in adult patients?

Most Common Site for Tracheostomy in Clinical Practice

The most common site for tracheostomy in adult clinical practice is between the second and third tracheal rings, typically 2 cm below the cricoid cartilage, performed via percutaneous dilatational tracheostomy (PDT) in the ICU setting. 1, 2

Adult Tracheostomy Site Selection

Standard Anatomical Location

• The second tracheal ring is the recommended target site for tracheostomy placement, with the procedure typically performed 2-3 cm below the cricothyroid membrane 3
• The average distance from the upper cricoid cartilage to the lower part of the second tracheal ring is approximately 25 mm, though this varies based on patient height and sex 3
• Between the cricoid cartilage and suprasternal notch, there are typically 11 tracheal cartilages and 10 annular ligaments spanning 6.9-8.2 cm 4

Technique-Specific Considerations

Percutaneous Dilatational Tracheostomy (PDT):

• PDT is the predominant technique in adult practice, particularly for critically ill patients requiring prolonged mechanical ventilation 5, 1
• The procedure targets the intercartilaginous space between tracheal rings, typically at or just below the second ring 1, 2
• Ultrasound guidance can help identify the optimal site and avoid vascular structures, reducing the need for bronchoscopic guidance 1

Open Surgical Tracheostomy (OST):

• OST allows direct visualization and precise placement at the second or third tracheal ring 2
• The choice between PDT and OST should be based on institutional expertise and available resources 1, 2

Pediatric Tracheostomy Site Differences

Critical Anatomical Distinctions

• In children, a vertical tracheotomy incision is mandatory rather than creating a cartilage window, to avoid stenosis at the tracheostomy site 5, 6
• The pediatric trachea is small, pliable, and difficult to palpate, with technical challenges magnified by the short neck and proximity of major vessels 5
• Stay sutures are placed on either side of the vertical tracheostomy to aid emergency tube replacement before stoma maturation 5, 6

Pediatric Technique

• Pediatric tracheostomies are typically open surgical procedures performed in the operating room, contrasting with adult practice 5
• Maturation sutures are used to accelerate stoma formation in children 5, 6

Site Selection Pitfalls and Complications

Common Technical Errors

Placement Too High:

• Puncture sites just below the cricoid cartilage occurred in some cases, with cricoid fracture documented in autopsy studies 7
• Higher placement (at cricoid level) may reduce distance to the brachiocephalic artery, though one study suggested glottic closure at this level paradoxically increased safety margins 8

Placement Too Low:

• Placement below the third tracheal ring increases risk of vascular injury from the brachiocephalic artery 7
• Lower placement may result in tracheal ring fractures and destruction, particularly with prolonged cannulation 7

Anatomical Hazards

• The brachiocephalic artery typically runs just below the thyroid gland and can be at risk with lower tracheostomy sites 9
• Tracheal ring fractures occurred in 11 of 12 patients in one autopsy series, with destruction of rings related to duration of cannulation 7
• Protrusion of the anterior tracheal wall with stenosis can occur from improper site selection 7

Clinical Decision Algorithm

For Adult Patients:

1. Measure 2 cm below the cricoid cartilage (cricothyroid membrane) 3
2. Adjust based on patient characteristics: taller patients and males typically require slightly lower placement 3
3. Use ultrasound to confirm anatomy and avoid vascular structures 1
4. Target the second tracheal ring or the space between the second and third rings 2, 3

For Pediatric Patients:

1. Perform open surgical technique with direct visualization 5
2. Create vertical incision avoiding cartilage window 5
3. Place stay sutures for emergency access 5, 6
4. Consider maturation sutures to accelerate healing 5, 6

Special Circumstances

• In patients with severe kyphosis or anatomical abnormalities, cricotracheostomy (removal of anterior cricoid cartilage) may be necessary when conventional sites are inaccessible 9
• In emergency situations requiring immediate airway access, cricothyrotomy should be preferred over tracheostomy due to faster procedure time and fewer vital structures in the cricothyroid membrane 4