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The surgical airway in the ICU 

The surgical airway in the ICU
The surgical airway in the ICU

Danja S. Groves

and Charles G. Durbin Jr

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date: 26 January 2021

Key points

  • Cricothyrotomy is an emergency surgical airway used to save a life when all attempts at securing a patent airway fail and arrest is eminent.

  • Compared with translaryngeal intubation, tracheostomy improves patient comfort, and leads to shorter length of intensive care unit (ICU) and hospital stay.

  • Tracheostomy relieves upper airway obstruction, protects the larynx and upper airway from damage, allows access to the lower airway for secretion removal, and provides a stable airway for patients requiring prolonged mechanical ventilation or oxygenation support.

  • Timing of tracheostomy remains controversial and should be individualized; however, early tracheostomy (within 7 days) seems to be beneficial in certain patient populations (head injury, medically critically ill).

  • Bedside techniques are safe and efficient, allowing timely tracheostomy with low morbidity.


Surgical airways are discussed in this section, and include emergency cricothyroidotomy and elective tracheostomy. Emergency cricothyroidotomy is reserved for that urgent situation when spontaneous ventilation is inadequate, manual ventilation unsuccessful, and translaryngeal intubation fails. It is a life-saving intervention, which can be rapidly performed with acceptable risk, using few surgical tools or a special device. While a ‘slash’ cricothyroidotomy may be performed with only a scalpel and tube, a specially-designed kit with a tube, dilator, and guide wire is more efficient and safer in inexperienced hands. Another approach to a lost airway is transtracheal needle ventilation, which will help to prevent lethal hypoxaemia, while achieving a secure airway by other means. The remainder of this chapter will discuss elective tracheostomy in intensive care unit (ICU) patients. Unlike the emergency surgical airway, this is a carefully considered, surgical approach to prolonged airway management. Some authors suggest a tracheostomy may be performed through the less vascular cricothyroid membrane, but most recommend placement at lower tracheal rings to reduce the chance of permanent laryngeal damage that can result from loss of the cricoid cartilage.

Of the purported advantages of tracheostomy, only improved patient comfort, early discharge from an ICU, and shorter length of ICU and hospital stay have any supporting data. There is a belief that patients are safer following tracheostomy, but even this basic assumption is unsupported by science. Evolution of percutaneous techniques are rapidly reducing the need for surgical tracheostomy. Timing of tracheostomy remains controversial.

Elective tracheostomy

Elective tracheostomy is performed in as many as 10% of patients requiring more than 7 days of mechanical ventilation. Prolonged respiratory failure is the most frequent indication for tracheostomy followed by decreased level of consciousness, poor airway protective reflexes, and severe alterations in physiology. The safety of tracheostomy techniques has improved and most are now performed at the patient’s bedside. There are two basic ways to perform tracheostomy—‘open’ or ‘surgical’ tracheostomy in which a formal neck incision is made, tissue planes are identified and incised, blood vessels ligated or cauterized, and a tracheal stoma surgically created and stabilized, or by percutaneous dilation, where the trachea is entered with a needle, and then a guide wire used to direct stoma creation and tube placement using tapered dilating devices.

Elective tracheostomy is used to relieve upper airway obstruction due to:

  • Tumour, surgery, trauma, foreign body, or infection.

  • Protect the larynx and upper airway from damage.

  • Allow access to the lower airway for suctioning and secretion removal.

  • Provide a stable airway for patients requiring prolonged mechanical ventilation or oxygenation support.

Although there are anecdotal reports using tracheostomy for emergency relief of airway obstruction, cricothyroidotomy remains the recommended approach when manual ventilation and intubation attempts have failed, and complete cessation of gas exchange occurs [1]‌.

Benefits of early elective tracheostomy?

Protection of the larynx and the upper airway from prolonged intubation is an important reason to perform a tracheostomy, and to consider early provision of this airway. Many anatomical structures are at risk from translaryngeal intubation. Vocal cord oedema and damage, laryngeal mucosal erosions, laryngeal scaring and stenosis, and recurrent laryngeal nerve damage can lead to permanent disability. The potential for recovery or successful surgical repair of many of these injuries is less with continued, prolonged intubation. Direct laryngeal examination demonstrates marked airway changes within several days of translaryngeal intubation. Usually, these early changes are reversible and there is gradual improvement in airway examination after the tube is removed from the larynx [2]‌. Prediction of progression with continued translaryngeal intubation is poor, but the consequences of injury are severe.

Improved patient comfort

Patients experience discomfort with persistent translaryngeal intubation and are more comfortable following tracheostomy [3]‌. Improved patient comfort and less requirements for sedation have been reported in several studies following placement of a tracheostomy. In a follow-up study of patients who were randomized to remain intubated translaryngeally for a prolonged period or receive an early tracheostomy, Blot et al. reported that oral comfort scores, mouth cleanliness, perception of change in body image, feelings of safety, and overall comfort were lower in the prolonged translaryngeal intubation group compared with those who were randomized to early tracheostomy [4]. Thirteen patients in this study who survived to hospital discharge, and had undergone both translaryngeal intubation and tracheostomy reported tracheostomy as the most comfortable airway of the two. Patient comfort alone may be enough to justify tracheostomy, rather than continuing with prolonged translaryngeal intubation if the risks of the two approaches are comparable. Other suggested advantages of elective tracheostomy and their strength of evidence are listed in Table 81.1.

Table 81.1 Suggested benefits of performing a tracheostomy in patients requiring prolonged intubation


Quality of literature showing benefit

Improved patient comfort

Uncontrolled reports, clinical opinion

Less need for sedation

Several RCTs

Lower work of breathing

Theoretical analysis, one small study

Improved patient safety

Clinical belief, but minimal data, some contradictory (see text for details)

Improved oral hygiene

Clinical observation

Oral intake more likely

Opinion only

Earlier ability to speak

Uncontrolled reports

Better long-term laryngeal function

Large uncontrolled reports

Faster weaning from mechanical ventilation


Lower risk of ventilator associated pneumonia

Controversial, data support for both sides

Lower mortality

One RCT supports, many do not; however, large RCT supports mortality not higher with tracheostomy

Shorter ICU and hospital stay

Several meta-analyses

RCT, randomized controlled trial.

Facilitated ventilator weaning and shorter length of stay

Elective tracheostomy may shorten duration of mechanical ventilation due to reduced work of breathing, the need for less sedation and analgesia, or because once a secure airway is in place clinician weaning behaviour changes [5]‌. A single prospective trial in surgical/trauma patients who were unable to pass a spontaneous breathing trial after 72 hours of mechanical ventilation, were randomly divided to continue translaryngeal intubation or proceed with immediate tracheostomy, demonstrated more rapid weaning following tracheostomy [6]. Several meta-analyses of randomized trials comparing earlier versus later tracheostomy confirmed that weaning is more rapid with early tracheostomy [7]. Earlier transition of a patient from the ICU remains a major demonstrable effect of tracheostomy, thus accruing fewer ICU and hospital days. However, this transition to a lower level care area may not be without risk.

Elective tracheostomy and patient safety

The presumed safety of having a tracheostomy in a patient managed outside an ICU or special care unit has come under scrutiny. In a prospective observational cohort study, Martinez et al. reported that patients discharged to the ward with a tracheostomy in place experienced three times the mortality of those who had received a tracheostomy, but who were decannulated prior to discharge to the ward [8]‌. Multivariate analysis identified three highly significant factors associated with increased ward mortality:

  • Lack of decannulation at ICU discharge.

  • Body mass index > 30kg/m2

  • Tenacious sputum at ICU discharge.

The last two would appear to be easier to manage with a tracheostomy, but most of the deaths on the ward were due to unexpected cardiorespiratory arrests, usually in the early morning hours when staffing may be compromised. Failure of monitoring of patients and of early treatment of airway problems may have played a part in the increased mortality in this group. Other groups have reported similar findings in less well-designed trials, while some have not identified having a tracheostomy at ward discharge a risk for increased mortality when corrected for other risk factors.

Others have noticed the additional risks of having a tracheostomy compared with standard translaryngeal intubation even when residing in an ICU environment. In 2000, Kapadia et al. reported airway accidents in 5046 patients intubated for 9289 days during a 4-year period. Of the 36 airway accidents, 26 occurred in the 5043 endotracheally-intubated patients—none were severe and no deaths occurred. Ten tracheostomy-related accidents occurred in 79 patients; six were severe and one resulted in death. Thus, even when monitored in an ICU, airway accidents associated with tracheostomy tubes occurred more frequently and resulted in higher mortality (10%) than in patients with conventional endotracheal tubes [10].

No fewer lung infections with elective tracheostomy

Since micro-aspiration of oral secretions through the stented larynx, past the endotracheal tube cuff is believed to contribute to development of infection; it was hoped that incidence of ventilator-associated pneumonia (VAP) would decrease with early tracheostomy. If there is an influence on the incidence or course of VAP from tracheostomy, it is small. In addition to the meta-analysis by Griffiths et al. mentioned previously, a recent review and meta-analysis of early versus later tracheostomy by Durbin et al. confirmed the observation of minimal effect on the incidence of VAP [9]‌. The fact that most patients are intubated through the larynx prior to tracheostomy will contaminate any study attempting evaluate elective tracheostomy and VAP association.

Timing of elective tracheostomy

Tracheostomy is indicated when the need for endotracheal intubation is or is projected to be prolonged. In older guidelines, tracheostomy was recommended after 21 days; more recently, it has been suggested that tracheostomy be considered within 2–10 days of intubation and a projected need for 14 days of intubation. In patients with severe multi-trauma and/or head injury with low Glasgow Coma Scores, elective tracheostomy at the earliest convenient time, often within 3–4 days of intubation, appears to afford some benefits [10]. An argument against early tracheostomy in patients with neurological abnormalities has been advanced by King et al. [11]. In their review, it appears that poor mental status alone is insufficient to require prolonged intubation and thus tracheostomy. They noted cough effectiveness, secretion quantity, and secretion viscosity all impact on the success of extubation in this group (and other patients) as well.

While it is clear that delaying extubation is associated with increased morbidity, and length of stay, the medical literature also demonstrates harm from extubation failure. Over 55 studies, involving more than 30,000 patients, suggest that the overall rate of extubation failure is approximately 12% (range 2–25%) [12]. One study from a medical ICU found that re-intubation resulted in an average 12 additional days of mechanical ventilation, 21 ICU days, 30 hospital days, and an increased need for tracheostomy and post-acute care hospitalization [13]. While patients requiring re-intubation tend to be sicker, multivariate analyses have shown that premorbid health status, severity of illness, and complications directly associated with re-intubation do not explain the increased mortality associated with extubation failure [14]. A direct correlation between increasing time to re-intubation and mortality has led some authors to suggest that clinical deterioration prior to reinstitution of mechanical ventilatory support is responsible for the increased mortality associated with extubation failure [15]. It has been suggested that careful monitoring and rapid intervention for respiratory failure developing following extubation may prevent this excessive mortality. However, this hypothesis has not yet been tested.

Unlike other reports, a study by Rumbak et al. demonstrated a remarkable mortality benefit of early tracheostomy in medical patients, with 32% mortality with early tracheostomy group and over 61% in the late group [16]. This trial was performed in three institutions and included severely-ill patients (APACHE score > 25) randomized to a percutaneous tracheostomy at 48 hours, or at 14 days or later. Low tidal volume ventilation, a ventilator-weaning protocol, and daily spontaneous breathing trials were used in all patients. In addition to mortality benefit of early tracheostomy, infections, and other complications were more common in the late tracheostomy group.

A recent large trial (909 patients) of early (<4 days) versus late tracheotomy (>10 days) demonstrated no survival benefit in the early group, but 44% of the late group either died or were weaned before receiving a tracheostomy [17].

Techniques of elective tracheostomy

Since Ciaglia first described his use of a guide wire and serial dilation technique for percutaneous tracheostomy in 1985, the popularity of this technique over the open technique has grown dramatically. Comparisons between surgical and percutaneous tracheostomy suggest more (but generally less severe) early complications during percutaneous placement, but fewer late problems. These are summarized in several papers by Durbin [18,19]. Initially, percutaneous dilatory tracheostomy was reserved for patients with few risk factors and favourable neck anatomy. With growing experience, the indications for percutaneous dilatory tracheostomy have been expanded and the patient exceptions that mandate a surgical tracheostomy have decreased. In the case of morbid obesity and moderate coagulopathy, percutaneous dilatory tracheostomy may afford better survival with fewer complications [20].

There are several variants on the percutaneous dilatory tracheostomy. A wire-guided sharp, cutting forceps developed by Griggs et al. gained early popularity, but is reported to have more acute problems, including bleeding and possibly decannulation tracheal risks. To improve safety, performance of percutaneous dilatory tracheostomy, use of bronchoscopic visualization during any technique, has been advocated. Creating the stoma with a single, long-tapered dilator, instead of using serial dilators has reduced procedural time and exposure of the team to the patient’s blood. A common, but usually insignificant complication is fracture of a tracheal ring. To reduce the likelihood of fracturing a tracheal ring during the forced dilation, Fantoni developed a method of passing the dilator from inside the trachea to the outside using a specially designed tracheostomy tube and a rigid bronchoscope. The complexity of this method has limited its dissemination. Another approach to reduce tracheal trauma has been developed using a screw-like device to gently separate the trachea rings (PercuTwist®), however, ring fractures still occur.

Ultrasonography of the neck identifies underlying anatomy with more precision than palpation. Tracheal rings are easily appreciated, and an overlying large vessel or thyroid gland can be seen and avoided during the procedure. With adequate experience it may be possible to correctly identify the entry point, but confirmation of correct entry and tube placement is best achieved with direct visualization using a fibre optic bronchoscope.

A variant on the dilator technique of tracheostomy placement begins by first creating a small surgical incision, using blunt dissection, and a gloved finger to palpate the trachea. The fingertip is used to identify the cricoid ring and tracheal rings. Operators using this technique often dispense with the fibre optic bronchoscope, relying on tactile identification of correct position for needle entry.

Whatever technique is chosen, there are major advantages to performing the procedure in the ICU. Unstable patients experience less deterioration in vital signs and avoid the risks of travel to the operating room. Multiple caregivers, already familiar with the patient, can monitor and care for the patient if the procedure is performed in the unit. Charges for the procedure are usually less when performed in the ICU, but actual costs are difficult to calculate, and payments are unrelated to charges or costs. Occasionally, a bedside procedure fails or a problem arises that would benefit from having operating room resources, such as high intensity lights or electrocautery. Whether to move a patient to the operating room if a surgical tracheostomy is needed—or to perform it in the ICU and bring required the equipment—is an institutional decision. Excellent results have been reported with all of the percutaneous dilatory, as well as surgical techniques performed in either the operating room or at the bedside. Local policy and resources guide the decision of where to perform a tracheostomy.


The overall rate of complications associated with tracheostomy is low. Reported complications range from pneumothorax, subcutaneous emphysema, haemorrhage, stomal infections, granulation tissue, tracheal stenosis, tracheomalacia, and to (rarely) death. These complications have to be weighed against the identified risks of long-term translaryngeal intubation, including oedema, inflammation, ulcerations, granulomas, arytenoid injury, and laryngeal or tracheal stenosis, fibrosis, or necrosis.


Absolute contraindications for tracheostomy, such as soft tissue infections or anatomic aberrations of the neck, are rare. Severe respiratory failure with refractory hypoxaemia and/or hypercapnia may be considered as relative contraindications requiring delay. Haematological and coagulation disorders may be considered as contraindications for tracheostomy, although percutaneous tracheostomy has been safely performed in patients with severe thrombocytopenia and other coagulation abnormalities.


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