All Emergency Physicians should be familiar with tracheostomy
care and the management of tracheostomy complications. Rapid assessment
and understanding of tracheostomies and their potential complications
can be lifesaving in the critically ill and tracheostomy-dependent
Although tracheostomies have been performed since ancient times,
they were perfected only during the past century. A Greek physician
named Asclepiades of Bismuth has been credited with performing the
first successful tracheostomy in 100 B.C.1 Two
of the four physicians summoned to President George Washington’s
deathbed were said to have argued for tracheostomy as his only means
of survival. In the 1800s, Trousseau reported successful tracheostomies
in more than 2000 cases of upper airway obstruction secondary to
diphtheria.2 Chevalier Jackson, in the twentieth century,
perfected the tracheostomy technique and reduced the operative mortality
from 25 percent to below 1 percent.3 This is roughly what
it remains today.
The important aspects of tracheostomy care include the assessment
of respiratory distress in the tracheostomy patient, proper suctioning
techniques, and assessment and evaluation of possible complications
arising from the tracheostomy itself or its placement. For the purposes
of this chapter, tracheostomy care is divided into routine care
and emergent care.
The trachea is a fibromuscular tube with approximately 18 to
20 cartilaginous arches extending from the cricoid cartilage to
the division into right and left mainstem bronchi (Figure 15-4).
The surface of the tracheal mucosa is covered with respiratory epithelium.
This epithelium is responsible for the formation of secretions,
mucociliary “elevator” movement of secretions
and debris, and humidification. Of note, the remaining part of the
upper respiratory tract (which is bypassed by the tracheostomy)
plays a major role in the warming and humidification of inspired
The terms tracheostomy and tracheotomy are widely interchanged
in current parlance. Tracheotomy refers to the actual incision through
the skin and the trachea, which is then kept open by a tracheotomy
tube. Tracheostomy refers to the procedure whereby the tracheal
opening is actually sutured to the skin incision. This creates a
more permanent orifice. The term tracheostomy is used in the remaining
sections of this chapter.
A tracheostomy is created by an incision at the level of the
second and third tracheal rings. After the subcutaneous tissue is
divided, an incision is made into the trachea. A hook is inserted
into the incision and used to stabilize the trachea while a tube
is placed in its lumen. The trachea is secured to the overlying
skin and the tube is secured in place. Further details can be found
in Chapter 15.
Tracheostomy tubes vary in their composition, angles, and types
and the presence or absence of a cuff. The basic tube consists of
an outer cannula and an inner cannula (Figure 16-1). The size of the
tracheostomy tube is usually defined by its inner diameter. The
outer cannula is the more permanent fixture in ...