Tracheostomy
What the Examiner Expects
Creation of a surgical airway through an anterior tracheal incision, typically between the 2nd and 3rd or 3rd and 4th tracheal rings. The examiner expects you to know the indications (prolonged intubation — usually considered at 10–14 days, upper airway obstruction, need for long-term pulmonary toilet, failed intubation), describe the open surgical technique (midline neck incision, divide platysma, separate strap muscles in the midline, identify and retract or divide the thyroid isthmus, enter the trachea with a horizontal incision or Bjork flap, insert tracheostomy tube under direct vision), and differentiate from cricothyroidotomy.
Key Examiner Focus Points
- Typically performed between tracheal rings 2–3 or 3–4
- Indicated for prolonged mechanical ventilation, upper airway obstruction, failed intubation
- Open surgical vs percutaneous dilational technique (Ciaglia)
- Avoid dividing the thyroid isthmus if possible; retract it superiorly
- Early complications: hemorrhage, pneumothorax, false passage, tube dislodgement
Common Curveballs
The tracheostomy tube is accidentally dislodged on POD 2 — the tract is immature
This is an emergency. An immature tract (< 7 days) will not maintain its patency. Do NOT blindly re-insert — risk of false passage into the pretracheal space. Orotracheal intubation is the priority. Once the airway is secured, the tracheostomy can be replaced under controlled conditions in the OR.
Massive hemorrhage from the tracheostomy site 2 weeks postop
Tracheo-innominate artery fistula — a life-threatening complication. Immediate temporizing measure: overinflate the tracheostomy cuff or place a finger through the tracheostomy stoma and compress the innominate artery against the posterior sternum. Emergent median sternotomy with ligation or bypass of the innominate artery is definitive.