Historically, tracheostomy has been performed for relief of obstruction of the upper airway (trauma, epiglottitis); when prolonged ventilatory support for respiratory failure is likely; for control of secretions in patients with bulbar lesions or closed head injuries; or for sleep apnea. In many centers, open surgical tracheostomy has been replaced with bedside percutaneous dilational tracheostomy. In patients with acute airway obstruction, cricothyroidotomy (“high tracheostomy”) is a better choice than tracheostomy, especially if the individual performing the procedure has little or no surgical training; if the procedure is being performed under less than ideal conditions in the emergency center or ICU; or if there is impending asphyxiation. The delay until tracheostomy is performed in patients with prolonged endotracheal intubation varies from center to center, but prospective data demonstrate the advantage of doing the procedure after 7–10 days. In patients with a head injury and poor neurological outcome a tracheostomy should be considered early in their care as this allows for improved oral care and optimal ventilator support. Recent evidence also indicates that patients who cannot be weaned with endotracheal tubes in place can often be weaned rapidly after a tracheostomy is performed. Finally, newer devices are available that enable patients with sleep apnea to be managed without tracheostomies.

Open tracheostomy is best performed in the operating room under local anesthesia supplemented by intravenous sedation after delivery of 100% oxygen by mask, endotracheal tube, or ventilating bronchoscope has been instituted. The patient's neck is hyperextended and a transverse incision is made over the second tracheal cartilage. The strap muscles are separated in the midline and the anterior trachea from the cricoid cartilage to the fourth tracheal cartilage is cleared, which often necessitates division of the thyroid isthmus between sutures. In many cases the posterior border of the thyroid isthmus can be mobilized without division and then retracted superiorly to provide adequate space for a tracheostomy. Either a vertical incision through the second and third cartilages or a three-sided, superiorly based flap (Bjork flap) between the second and third cartilages is made. It is imperative that notification of the tracheal incision be given to the anesthesiologist, as this is the time to deflate the balloon of the endotracheal tube, decrease oxygenation, and also avoid unnecessary cautery. The tracheostomy tube is then inserted as the anesthesiologist removes the endotracheal tube. The tracheostomy tube is secured to the skin with permanent sutures to avoid accidental decannulation.