A Simple Guide To Tracheostomy: Benefits, Procedural Steps, And Clinical Tips

Why Focus on Tracheostomy?

When critically ill patients struggle at the edge of life and death due to acute airway obstruction, severe trauma, or the need for long-term mechanical ventilation, time equals life. At such moments, establishing a stable and reliable airway is crucial.

Tracheostomy is exactly such a life-saving surgical technique. By creating a surgical opening in the anterior wall of the trachea at the neck, this procedure allows air from outside to bypass obstructions or pathological changes of the upper airway and flow directly into the lungs. It buys valuable rescue time for the patient and lays the foundation for subsequent life support.

This procedure holds unique clinical value in numerous life-threatening or severely respiratory-impairing situations. Understanding its indications, mastering a standardized procedural approach, being familiar with perioperative management principles, and avoiding potential risks are of great importance for healthcare providers in emergency medicine, intensive care, anesthesiology, and other related fields.

What’s Tracheostomy?

In simple terms, a tracheostomy is a surgical procedure performed in emergency or specific clinical settings to establish an artificial airway. Its core operation is making an incision in a defined area of the anterior tracheal wall at the neck, thereby creating a direct opening into the airway.

The artificial channel formed by the procedure is called the stoma (sometimes also referred to as the tracheal opening or breathing hole), which serves as a new pathway for air to flow in and out of the lungs.

Distinction:

· Tracheostomy: The surgical process itself — creating the opening in the trachea.

· Trach stoma: The actual surgically created opening in the tracheal wall after the procedure, functioning as the passage for air exchange.

In daily clinical practice, tracheostomy is not uncommon.

It is frequently performed in situations requiring urgent airway management, such as in emergency departments dealing with severe upper airway obstruction or trauma.

It is a common choice in intensive care units (ICUs) for patients who require prolonged ventilatory support, providing a safe and stable airway.

It is also applied for patients with neuromuscular diseases, chronic obstructive pulmonary disease (COPD), or other conditions that impair airway protection or reduce autonomous breathing capacity, thereby improving breathing efficiency and enabling long-term care.

Thus, tracheostomy remains a critical modern medical technique for airway management.

What Is the Purpose of Tracheostomy?

Tracheostomy is by no means an optional procedure for surgeons; rather, it is an indispensable, and sometimes life-determining, clinical intervention in specific situations. Its core value lies in bypassing or replacing the compromised physiological airway, thereby reconstructing a reliable pathway for ventilation. Below are several common and urgent indications for this procedure:

1. Relief of Critical Upper Airway Obstruction

When severe foreign body aspiration, laryngeal edema, specific infections, trauma (such as laryngeal or tracheal injury), or tumor compression prevents the maintenance of oral or nasal airway patency, tracheostomy offers the most direct and rapid method to remove the obstruction and restore oxygen supply.

2. Establishing Long-Term Safe Mechanical Ventilation

For patients requiring prolonged ventilator support (generally when intubation is expected to last more than 1–2 weeks), tracheostomy provides significant advantages over orotracheal or nasotracheal intubation. These include improved comfort, reduced risk of laryngeal mucosal damage (such as ulcers or vocal cord injury), easier management of airway secretions, and the opportunity to begin weaning trials when conditions allow.

3. Addressing Long-Term Airway Maintenance/Protection Issues Caused by Chronic Diseases

Some patients with neuromuscular disorders, spinal cord injuries, chronic obstructive pulmonary disease (COPD), or other conditions may have severely impaired ability to clear respiratory secretions or swallow effectively. This leads to recurrent aspiration and a dramatically increased risk of pneumonia. Tracheostomy provides a convenient channel for direct suctioning of pulmonary secretions and allows for the use of cuffed tracheostomy tubes, which effectively separate the airway from the digestive tract, thereby reducing aspiration risk.

4. A Critical Backup Option When Oral Intubation Is Impossible

In patients with severe head and neck trauma, extreme anatomical abnormalities, major maxillofacial fractures, or conditions such as trismus that make safe or effective oral intubation impossible, tracheostomy often becomes the only feasible means of establishing a controlled airway.

Direct Connection to Medical Resource Needs:

Whether in emergency departments responding swiftly to airway crises, intensive care units managing prolonged ventilatory support, departments treating patients with chronic respiratory failure, or in preoperative preparation for complex airways, the frequent application and irreplaceable role of tracheostomy determine that supporting consumables — including high-quality tracheostomy tubes of various types, fixation straps, incision care kits, suction system components, and more — must always be well-prepared and immediately available in the relevant clinical units.

How to Perform a Tracheostomy

1. Precise Localization: Extend the patient’s neck moderately and palpate key anatomical landmarks (such as the thyroid cartilage and cricoid cartilage). Carefully determine the surgical incision site, which is usually located at the level of the second to third tracheal rings.

2. Establishing the Surgical Pathway: Make a midline incision through the skin and subcutaneous tissues. Gently separate the soft tissues and strap muscles to clearly expose the anterior tracheal wall. Maintain a clean surgical field and ensure that critical vessels and nerves are identified and avoided.

3. Creating the Tracheal Window: Perform a controlled incision on the exposed tracheal wall. The classic method involves a transverse incision between the targeted tracheal rings, or raising a small tracheal flap with its base positioned inferiorly. This step creates the tracheal stoma — a direct portal leading into the lungs.

4. Tube Insertion: Gently insert a preselected tracheostomy tube of appropriate size (with obturator, if applicable) through the newly created stoma into the tracheal lumen. Once the tube is in place, promptly remove the obturator. The tracheostomy tube then immediately becomes the new airway connecting external air to the lungs.

5. Position Confirmation: Confirm the correct placement of the tube by observing synchronized chest expansion, auscultating for clear and symmetrical breath sounds in both lungs, and monitoring capnography for exhaled carbon dioxide waveforms. Once correct placement is verified and there is no misplacement into surrounding tissue, secure the tube with specialized fixation straps. The straps should be tight enough to prevent accidental dislodgement but not excessively tight, to avoid compromising circulation or causing discomfort.

Emergency vs. Elective Procedures

-Emergency Tracheostomy

In life-threatening situations where asphyxiation is imminent and conventional intubation has failed, the priority is speed above all else. The surgical path from skin incision to tube insertion is simplified to the maximum extent possible (in some cases, even direct needle puncture and dilation are performed). The procedure relies heavily on the surgeon’s experience to handle potential bleeding and anatomical distortion. The ultimate goal is to achieve airway ventilation within seconds. In this scenario, the tracheostomy tube becomes the sole lifeline for survival.

-Elective Tracheostomy (Operating Room/ICU)

Performed under relatively stable and controlled conditions (often as a planned procedure or at the ICU bedside). Emphasis is placed on systematic precision. Tissue handling is meticulous, hemostasis is thorough, anatomical structures are clearly separated, and the method of tracheal opening (transverse incision or flap technique) is chosen deliberately. Tube selection and position verification are carried out with great care, followed by secure suturing and fixation.

The primary objective is to establish a safe, stable airway suitable for long-term management. In this context, the tracheostomy tube is not only a ventilation device but also a bridge toward comfort-focused care and potential rehabilitation.

Types of Tracheostomy

1.Emergency Tracheostomy

Indicated in cases of immediate respiratory failure, complete upper airway obstruction, or when all other ventilation methods have failed in a life-threatening crisis.

The primary goal is to open the airway before cardiac arrest occurs, racing against time. The procedure relies on direct and simplified techniques to access the trachea — here, speed overrides precision.

Commonly performed at the bedside in situations such as severe trauma, asphyxiation, laryngeal edema caused by burns, or impending intubation failure.

Rapid puncture and dilation techniques are often used, and some degree of subsequent bleeding or tissue injury is tolerated in exchange for immediate ventilation.

2.Conventional/Open Tracheostomy

A standardized surgical procedure performed in a strictly controlled environment, such as an operating room or ICU bedside.

Involves a formal cervical incision with stepwise dissection to expose the anterior tracheal wall, followed by a precise incision at the designated tracheal rings and secure tube placement.

This method allows for clear identification and management of surrounding structures such as vessels and the thyroid isthmus, significantly reducing perioperative complications.

It is the preferred option for patients requiring a safe and reliable long-term airway, such as those with neuromuscular diseases needing ventilatory support, patients unable to wean from mechanical ventilation, or critically ill individuals expected to need intubation for more than two weeks.

3.Permanent Tracheostomy

Performed when natural airway function is completely and irreversibly lost, such as in patients after total laryngectomy, or when permanent airway protection is required, such as in cases of high cervical spinal cord injury with chronic inability to clear secretions.

In this procedure, the tracheal mucosa is sutured directly to the neck skin to create a permanent epithelialized stoma.

The stoma itself remains functional long-term, eliminating the need for repeated intubation procedures.

4.Chronic Tracheostomy Management (Often Misunderstood as a “Type”)

Strictly speaking, this is not a separate surgical form, but rather the long-term management of tracheostomy tubes that remain in place for more than two weeks.

The focus lies on comprehensive long-term care, including:

· Continuous evaluation of stoma stability.

· Choosing appropriate cuffed tubes to minimize micro-aspiration.

· Proper humidification and suctioning management.

· Scheduled tube replacement protocols.

· Strict infection prevention strategies.

This management is essential for patients with permanent tracheostomies as well as those who, despite some possibility of eventual decannulation, must live with long-term airway support (e.g., patients with amyotrophic lateral sclerosis).

Frequently Asked Questions About Tracheostomy

1.Is a tracheostomy permanent?

In the vast majority of cases, no.

The primary goal of tracheostomy is to address temporary respiratory problems such as upper airway obstruction, prolonged mechanical ventilation, or secretion clearance. Once the patient regains spontaneous breathing ability, the tube can be removed, and the stoma at the neck typically closes on its own within several days to a week.

Only in cases where natural airway function is completely and permanently lost (e.g., after total laryngectomy) is a permanent tracheostomy performed.

2.Can tracheostomy patient drink water?

In the early postoperative stage (about 1–3 days), oral intake must be strictly prohibited.

Swelling of the pharynx, tube pressure, and impaired swallowing coordination create a high risk of aspiration, which can lead to severe pneumonia. During this time, patients must rely on nasogastric feeding or parenteral nutrition.

Later recovery is highly individualized.

Only after thorough evaluation by a speech and swallowing therapist (e.g., via videofluoroscopic swallow study) confirming no signs of aspiration and reliable swallowing function, may patients cautiously attempt small amounts of thickened liquids.

Clear water usually carries the highest aspiration risk, and in the early recovery stage it is often still strictly restricted or prohibited.

3.Can patients with a tracheostomy eat food?

Restoring normal oral feeding is not guaranteed and often challenging:

· Strict prohibition in the early stage: Same reasoning as with drinking water — aspiration risk is extremely high.

· Complexities in long-term management: For some patients, especially those with neurological impairments, coordination of pharyngeal muscles remains severely compromised even with long-term tracheostomy, making safe swallowing of solid food impossible.

· Professional evaluation and training required: If swallowing assessments are favorable, a cuffed tracheostomy tube may be used (inflated appropriately to block the esophageal entrance), and small portions of soft food may be attempted. During feeding, meticulous suctioning and strict monitoring are essential. For many long-term tube-dependent patients, a gastrostomy feeding tube remains the safest option.

4.How long does a tracheostomy take?

The duration depends heavily on the setting and urgency:

· Emergency bedside procedure: In critical rescue scenarios, an experienced team may secure an airway within 1–3 minutes (e.g., using rapid puncture techniques). However, under high stress, bleeding and other issues often extend the actual time.

· Standardized open procedure (OR or ICU preventive tracheostomy): From anesthesia and preparation to secure tube fixation, the full process usually takes 20–45 minutes. Complexity, surgeon experience, and comorbidities (e.g., bleeding difficulties) can prolong the operation.

· Permanent tracheostomy (e.g., during laryngectomy): This is part of a more comprehensive surgical approach and often takes over 1 hour.

5.Benefits of tracheostomy over intubation?

For patients expected to need respiratory support beyond 7–10 days or long-term ventilation, tracheostomy provides clear advantages:

· Significantly improved laryngeal protection and comfort

- The tube does not continuously rub against or compress the vocal cords, reducing the risk of long-term complications such as ulcers, granulomas, or persistent pain.

· Enhanced airway management and respiratory training

- Patients tolerate the tube better, often requiring less sedation.

- Suctioning is more efficient, and oral care is no longer restricted.

- Some conscious patients may attempt speech (with cuff protection) or even gradual spontaneous breathing trials as part of ventilator weaning.

· Greater stability and easier nursing care

- Secure fixation lowers the risk of accidental dislodgement.

- Oral and nasal hygiene becomes simpler, supporting better routines for oral activity.

- These advantages directly improve quality of life and reduce complications in ICU or chronic critical illness settings.

In summary: A tracheostomy tube establishes a more durable, better-tolerated, and functionally supportive airway than prolonged orotracheal intubation. In long-term care, it holds central value by enabling safer ventilation, facilitating nursing care, and preserving aspects of patient quality of life.