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Tracheostomy: indications, technique and complications

Tracheostomy is a surgical opening in the trachea that bypasses upper obstruction or allows prolonged ventilation and clearing of secretions; the great dangers are displacement or blockage of the tube in the first week, before the tract has matured, and innominate artery fistula — and every team needs a clear emergency algorithm.

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Why it matters in the exam

Indications: prolonged ventilation, upper airway obstruction (tumour, bilateral vocal fold palsy, oedema after radiotherapy), clearing secretions, severe sleep apnoea that has not responded to treatment, and as part of major head and neck surgery. The TracMan trial (2013) found no difference in mortality between early tracheostomy (within 4 days) and late (after 10 days), but early tracheostomy reduces the need for sedation. Percutaneous dilatational tracheostomy is safe in adults in intensive care when the anatomy is favourable; open tracheostomy is preferred in a difficult neck, in children and with a bleeding disorder.

In the open technique the trachea is entered between the second and fourth rings; a Björk flap can be left to ease reinsertion. In children a vertical tracheal incision is made without removing cartilage, with stay sutures on both sides — to reduce stenosis and ease reinsertion of a dislodged tube. Cricothyroidotomy is an emergency route, and traditionally it was converted to tracheostomy within 72 hours to prevent subglottic stenosis.

Early complications: bleeding, pneumothorax, subcutaneous emphysema, and displacement or blockage of the tube — especially dangerous in the first 5 to 7 days. Innominate artery fistula usually appears between 3 days and 6 weeks, and is often preceded by a "sentinel bleed"; immediate treatment is cuff overinflation or finger pressure through the stoma toward the sternum, and immediate transfer to theatre. Late complications: tracheal stenosis, granulation and tracheoesophageal fistula. Decannulation follows downsizing and capping the tube for 24 to 48 hours without distress. In the NTSP algorithm: call for help, give oxygen to the face and the stoma, check patency with a suction catheter, deflate the cuff, and if there is no patency remove the tube and ventilate via the mouth or the stoma. After total laryngectomy the patient breathes only through the neck stoma.

Key points

• Indications: prolonged ventilation, upper obstruction, secretions.
• First week: displacement is dangerous.
• Sentinel bleed → innominate artery fistula.
• NTSP algorithm for blockage or displacement.
• Decannulate after capping for 24 to 48 hours.

Summary table

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Sources

• National Tracheostomy Safety Project (NTSP) emergency algorithms, 2012, updated 2023 — Blocked or displaced tracheostomy
• Young D et al. Effect of early vs late tracheostomy placement on survival (TracMan, JAMA), 2013 — Main results
• AAO-HNS Clinical Consensus Statement: Tracheostomy care, 2013 — Tube changes, decannulation and complications

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.