Dissection

• Divide the Platysma and Retract Laterally
• Retract the Thyroid Isthmus Superiorly
  • May Require Division of the Thyroid Isthmus to Access the Trachea
• Expose the Trachea and Identify the Target Site (Below the Second or Third Tracheal Rings)
• Ensure Meticulous Hemostasis Before Puncturing the Trachea
  • *Do Not Want to Use Electrocautery Once the Trachea is Open – High Oxygen Content is a High Risk for Fire

Consider Placing Stay Sutures

• Temporarily Deflate the Endotracheal Tube Cuff (Prevent Needle from Catching the Balloon)
• Place Non-Absorbable Sutures (2-0 Prolene) Far Laterally on Either Side of the Trachea at the Target Site
• Air Knots are Tied to Secure the Suture but Allow Later Removal
• The Sutures are Secured to the Skin with Tape or Steri-Strips at the End of the Case
• *Stay Sutures are Used to Stabilize the Trachea to Assist in Tracheostomy Replacement in the Case of Accidental Dislodgment

Place the Tracheostomy

• Create a Tracheotomy with an #11 Blade Scalpel Under the Second or Third Tracheal Ring
• Tracheotomy Technique:
  • “X” Incision
  • “+” Incision
  • “T” or Inverted-“T” Incision
  • Square Incision
  • “U” Incision
• Insert a Tracheal Dilator and Expand to Dilate the Opening
• Pull Endotracheal Tube Back Under Direct Visualization to Just Above the Tracheostomy Site
• Insert the Tracheostomy Tube
• Insert the Inner Cannula into the Tracheostomy Tube
• Inflate the Tracheostomy Cuff
• Fully Remove the Endotracheal Tube from Above

Secure

• Secure the Tracheostomy with a Tracheostomy Tube Holder (Strap) Around the Neck
• Consider Securing the Tube Itself to the Skin with 2-4 Sutures
  • Use is Debated – Risk for Wound Complications but Does Not Decrease the Risk of Accidental Decannulation