tracheostomy

Tracheostomy involves surgical or percutaneous placement of a tube directly into the trachea, allowing air to bypass the nose, mouth, and pharynx. Indications include prolonged mechanical ventilation (typically >7-14 days), upper airway obstruction (tumors, trauma, bilateral vocal cord paralysis), inability to protect the airway (neuromuscular disease, severe neurologic injury), and need for pulmonary toilet in patients with excessive secretions. Compared to prolonged endotracheal intubation, tracheostomy reduces laryngeal injury, subglottic stenosis, and vocal cord damage, and is generally better tolerated, allowing for reduced sedation, improved oral hygiene, and easier weaning from the ventilator. It also decreases dead space and work of breathing. Complications can be immediate (bleeding, pneumothorax, esophageal injury, misplacement) or delayed (tracheal stenosis, tracheomalacia, tracheoesophageal fistula, tracheoinnominate artery fistula—a life-threatening complication presenting with massive hemorrhage). The tracheoinnominate fistula is a classic board topic: it typically occurs 1-2 weeks post-procedure and presents with a sentinel bleed followed by massive hemorrhage; management involves finger occlusion of the stoma against the sternum while awaiting surgical repair. Percutaneous dilational tracheostomy (bedside, using Seldinger technique) is increasingly used in ICU settings as an alternative to open surgical tracheostomy, with comparable outcomes in appropriately selected patients. Anatomically, the trachea lies posterior to the isthmus of the thyroid gland, which sometimes must be divided during the procedure. The recurrent laryngeal nerves lie in the tracheoesophageal grooves and are at risk of injury.