Field Notes on Tracheostomy Part 1: The Basics

Hello! This is not a comprehensive textbook on how to manage patients with tracheostomies. This is a humble collection of practical brief notes, as requested by a twitter friend. This is a primer. For more extensive information, feel free to consult the big texts.


Someone once said that a tracheostomy tube is a piece of plastic that sits between 12 specialties. I can only count 9 (ENT, ICU, Anaesthesiology, Respirology, Thoracic, Nursing, Speech Pathology, Physiotherapy, Emergency), but I get the drift. Many of us will manage patients with tracheostomy tubes and find it a little uncomfortable. I hope to give you some practical basics to hang on to. There would certainly be tracheostomy protocols in most of the hospital you work with. Do read them.

Tracheostomy is a tracheo-cutaneous airway fistula surgically created to provide direct cannulation of the trachea and therefore direct ventilation of the lower airway. The opening on the skin is called a tracheostoma. (I know, some purists would say that tracheostoma refers only to the permanent stomal opening of the trachea after a laryngectomy- removal of the larynx and separation of the digestive and upper airway tracts – another topic altogether.)

How is it inserted?

Two main ways. Open surgical tracheostomy via skin incision and dissection of anterior neck tissues down to tracheal cartilages. Secondly, percutaneously through needle insertion and guidewire directed dilatation. This is usually assisted by a flexible scope to confirm position intraluminally. There are many percutaneous tracheostomy kits available. As you can imagine, there are advantages and disadvantages to both methods and complications associated with them.

Why tracheostomies?

In the emergency situation: to secure the airway in the context of upper airway pathology (eg. Laryngeal tumours, epiglottitis, Ludwig’s angina, base of tongue cancer, facial fractures, etc.)

In the elective situation: for prolonged intubation and ventilation (ICU patients, long term ventilation and toileting in neuromuscular disorders, etc), as adjunct to other procedures (eg. Major head and neck maxillofacial resection and reconstruction), and congenital airway pathologies (vocal fold palsies, craniofacial syndromes, etc.)

Tube choices

This can be quite confusing, but it’s actually quite logical. There are many options available, and we choose them on the basis of the indications.

First, choose the size in the same way you would choose an endotracheal tube size. Therefore most adult would be a size 7 or 8.

Secondly, do you need a cuff (balloon)? Usually the answer is yes. Having a cuff would provide a seal around the tube for ventilation, and prevent secretions or blood from going down into the lower airway. When would you choose an uncuffed tube? When the patient is able to breathe on their own and maintain their own secretions by swallowing. This is usually when the patient is expected to be tracheostomy tube dependent for a prolonged period.

Thirdly, do you need longer tubes? Depending on the anatomy of the neck, sometimes you need to choose a longer tube. The extension can be on the proximal or distal segment. In an obese neck, we need a proximal extension. In a long thin neck and high tracheostomy, we need distal extension. Some tubes have a flange that can be moved so the proximal extension length can be modified to the patient’s neck thickness.

Easy enough?

Other special features:

Inner cannula: an inner tube or cannula allows the lumen to be easily cleaned regularly. This is important as blood, mucous, and sputum can occlude the lumen easily. Pull it out, wash it out, put it back in. Easy. Note also though that an inner cannula narrows the internal diameter of the tube. The smaller you go, the harder the airflow.

Suction: Some tubes have suction-aid: a small suction hole just above the cuff so that secretions above the cuff can be suctioned. Very useful.

Fenestration: some uncuffed tube provide fenestration opening on the superior surface of the tube. This is useful for vocalization in patients who are tracheostomy dependent. Patients can breathe around and through the tube fenestration to project air into the larynx and oral cavity, and therefore speak.

Materials: most tubes are made of hard plastic. Some are made of flexible silicone to reduce pressure around the neck and trachea. There are even those made of metal for long term tracheostomy dependent patients. Note that different materials will result in different sizes of internal and external diameter of the tube. So a size 8 tube may have different outer diameters based on the materials, which means it may be a little wider and harder to insert.

Tracheostomy care in the first few days

I tell my residents that there are 3 significant potential complications within the first few days of tracheostomy: tube dislodgement, tube occlusion and bleeding. Tracheostomy tube care is critical in the first few days. Positioning of the neck and the tube is important, particularly as patients are being rolled or moved in bed. If the tube is not stitched to skin, a firm tape around the neck is essential. Sometimes firm padding around the flange is helpful. Humidification is important as the humidifying properties of the nose is bypassed in patients with tracheostomy. Humidification prevents dried mucous to become an obstructing plug in and around the tube. The use of inner cannula is recommended and the inner cannula should be washed and cleaned several times a day to prevent crusting and occlusion. Regular suctioning transorally above the cuff and through the tube under the cuff is necessary to prevent excessive secretions from seeping down into the lower airway and interfering with ventilation. Most newly tracheostomised patients are not able to swallow well or clear secretions with the tube in situ. Remember that patients are not able to produce an effective cough with tracheostomy tube in situ. Suctioning takes over the toileting properties of a cough. It is normal for small amounts of blood and mucous to be expressed around the stoma and during suctioning. Simple packing with gauze and suctioning usually resolve most problems.

What about tube dislodgement or excessive bleeding? What about change of tracheostomies? We’ll talk about that in Part 2: Problems.