Tracheostomy: Indications and Types 

Definition 

A tracheostomy is a surgically created opening in the anterior wall of the trachea to establish a direct airway, usually between the 2nd and 4th tracheal rings. 

Indications for Tracheostomy 

1. Upper airway obstruction (tumours, trauma, oedema, vocal cord paralysis) 
2. Prolonged mechanical ventilation (usually >7–14 days) 
3. Airway protection in patients with reduced consciousness or neuromuscular disease 
4. Facilitation of pulmonary toilet in patients with excessive secretions. 
5. Elective use during major head and neck surgeries 

Types of Tracheostomy: 
 
Surgical (Open) Tracheostomy: 
– Performed in operating theatre or ICU 
– Used in difficult anatomy or paediatric patients 
 
Percutaneous Dilatational Tracheostomy: 
– Performed at bedside in ICU 
– Less invasive and most commonly used 

Mini-tracheostomy: 
Performed at the bedside 
Used for secretion management not ventilation 

Types of Tracheostomy – Based on Duration 
 
Temporary Tracheostomy: 
– Intended for eventual decannulation 
 
Permanent Tracheostomy: 
– Performed after total laryngectomy or irreversible airway obstruction 
 
Types of Tracheostomy Tubes 

Cuffed Tube: 
– Used during mechanical ventilation 
– Prevents aspiration and prevents air escaping around the tube 
 
Uncuffed Tube: 
– Used in spontaneously breathing patients 
 
Fenestrated Tube: 
– Allows speech; the tube has a hole in it to allow air to flow over the vocal cords and therefore speech 
 
Inner Cannula Tube: 
– Is removed to allow easy cleaning; it is customary to have a spare at every bedside as inner tube change can be needed frequently and the tube can be difficult to clean (note inner cannula needs to be in situ to attach ventilator tubing. 

Complications 

Early: Bleeding, pneumothorax, tube displacement 
Late: Tracheal stenosis, infection, tracheoesophageal fistula 

Key Nursing Points 

– Monitor cuff pressure (20–30 cm H2O) in an inflated cuff 
– Provide humidification 
– Keep spare tracheostomy tubes 
– Ensure proper suctioning and tube care 
– Always deflate cuff with a speaking valve!

A sign is placed above the patients bed to indicate they have an altered airway (tracheostomy or, less common, laryngectomy).
 
An emergency tracheostomy box is kept at every bedside, there will be a local checklist for the contents but it typically comprises of: 
Spare tracheostomy – 1 same size and 1 a size smaller 
Suture cutter 
Spare dressing 
10ml syringe 
Gauze 
Tracheostomy dilator 
Tracheostomy tube ties