Historically, tracheostomy has been performed for relief of obstruction of the upper airway (trauma, epiglottitis); when prolonged ventilatory support for respiratory failure is likely; for control of secretions in patients with bulbar lesions or closed head injuries; or for sleep apnea. In many centers, open surgical tracheostomy has been replaced with bedside percutaneous dilational tracheostomy. In patients with acute airway obstruction, cricothyroidotomy (“high tracheostomy”) is a better choice than tracheostomy, especially if the individual performing the procedure has little or no surgical training, if the procedure is being performed under less than ideal conditions in the emergency center or intensive care unit, or if there is impending asphyxiation. The delay until tracheostomy is performed in patients with prolonged endotracheal intubation varies from center to center, but prospective data demonstrate the advantage of doing the procedure after 7 to 10 days. Recent evidence also indicates that patients who cannot be weaned with endotracheal tubes in place can often be weaned rapidly after a tracheostomy is performed. Finally, newer devices are available that enable patients with sleep apnea to be managed without tracheostomies.
After instituting the delivery of 100% oxygen by mask, endotracheal tube, or ventilating bronchoscope, open tracheostomy is best performed in the operating room under local anesthesia supplemented by intravenous sedation. The patient's neck is hyperextended and a transverse incision is made over the second tracheal cartilage.