There are two main methods of performing a tracheostomy, the STANDARD SURGICAL method and the PERCUTANEOUS DILATATION technique. Patients will be consented for tracheostomy by a doctor who will explain the procedure, benefits and risks.

STANDARD SURGICAL TRACHEOSTOMY (SST) – performed in the operating theatre, usually by an Ear, Nose and Throat (ENT) surgeon. Can be performed under local or general anaesthetic.

Photo of patient in a theatre setting>

Method:

• A horizontal incision, approximately 4-6cm in length, is made over the second and third cartilage rings.
• An incision is made into the trachea.
• A window, big enough to take an appropriate sized tube, is cut into the anterior aspect of the tracheal cartilages.
• The tracheostomy tube is inserted into the opening.
• Sutures are used to close the wound; normally removed after 7-10 days.
• The tube is secured by tracheostomy ties and sutured in place using a thick silk stitch. These sutures are placed either side of the tube, through the loop of the tube’s flange, to prevent accidental decannulation in the immediate post-operative period.
• The tube should only be changed once a tract has formed between the trachea and skin, usually 48-72 hours; however, it is best to wait at least 5 days before performing the first tube change (Price 2004)

Advantages:
This technique will be used in the following circumstances:

• Emergency situations
• Patients with obstructed airways
• Patients under 16 years of age
• Where anatomy restricts the ability to extend the neck, for example, severe kyphosis, cervical spine trauma, arthritis etc
• Where anatomy makes palpable identification of neck landmarks difficult, for example, neck mass (a goitre or tumour), gross obesity, neck oedema
• Where there are abnormalities in blood clotting
• Used for elective procedures, for example, post-operative oedema following head and neck surgery

Disadvantages:

• An unstable ICU patient requires transfer to theatre for the procedure
• Requires co-ordination of ENT surgeons and waiting time for available theatre space
• Reported greater incidence of post op complications compared to PDT, for example, increased wound infection and breakdown due to tissue trauma, tracheal stenosis, and scarring (Van Heurn et al. 1996, Worthley & Holt 1992, Law et al. 1997)

Method:

• Adequate pain relief, sedation, and neuromuscular blockade is administered
• The endotracheal tube (ETT) is withdrawn to above the chosen insertion site whilst still allowing ventilation of the patient (most anaesthetists use the guidance of a fibreoptic bronchoscope)
• A small horizontal incision is made at the chosen insertion site, usually between the second and third tracheal ring
• A needle is inserted to confirm entry into the trachea, a guide-wire is then inserted and a dilator is advanced over the wire to increase the size of the stoma. When the desired diameter is achieved, a tracheostomy tube is inserted
• The tracheostomy tube is then secured in place and the ETT is fully withdrawn

Advantages:

• Performed at the ICU bed-side therefore less restraints than SST, for example, theatre availability, accessing surgeons, and time involved co-ordinating transfer from ICU to theatre
• Reduces the time between decision to operate and the actual procedure; tracheostomy can be performed the day the decision to operate is made (compared to up to four days with the SST), thus reducing the risks
• associated with prolonged ETT intubation (Hoffman 1994, Friedman 1996)
• Transportation of critically ill patients from ICU to the operating theatre is avoided therefore reducing the risks associated with the transfer of an unstable patient (Smith et al. 1990)
• Easier and faster than SST; it can be carried out in as little as 15 minutes in experienced hands
• Associated with fewer complications than SST (Van Heurn et al. 1996, Worthley & Holt 1992, Law et al. 1997)
• Less expensive; cuts out additional costs such as theatre personnel and anaesthesia

Disadvantages/Contra-indications:

• Contra-indicated for patients with local infection and or/inflammation at the operation site
• Contra-indicated in patients with coagulopathy
• Not suitable for patients under 16 (some quote 12 years)
• Not suitable for patients with obvious deformities of the airways that make identification of landmarks, such as the cricoid cartilage, difficult to palpate
• Unsuitable for patients who have the inability to extend the neck
• The snug-fit of the tube into the stoma may make re-cannulation difficult, especially in the case of early (1-5 days) accidental decannulation
  

References
Friedman, Y,. (1996) Indications, timing, techniques, and complications of tracheostomy in the citically ill patient. Current Opinions Critical Care, 2:47-53
Hoffman, L.A., (1994) Timing of tracheostomy: What is the best approach? Respiratory Care, 39: 378-385
Law, R. C., Carney, A.R. and Manara, A.R., (1997) Long-term outcomes after percutaneous dilatation tracheostomy. Anaesthesia: 52, 51-56
Price, T., (2004) Surgical Tracheostomy. Tracheostomy: A Multiprofessional Handbook. Cambridge University Press, Cambridge: 35-58
Smith, I., Fleming. S., Cernaianu. A., (1990) Mishaps during transport from the intensive care unit. Critical Care Medicine, 18: 278-281
Van Heurn, E.L.W., Goei, R., De Ploeg, I., Ramsay, G. and Brink, P.R.G., (1996) Late complications of percutaneous dilatation tracheostomy. Clinical investigations in critical care. Chest, 110: (6), 1572-1576
Worthly, I., Holt, A., (1992) Percutaneous tracheostomy. Intensive Care World, 9(4), 187-192