3 The procedure
3.1 Translaryngeal tracheostomy is a method for inserting a tracheostomy tube using direct endoscopic visualisation. It is usually carried out with the patient under general anaesthesia with muscle relaxation. The patient lies supine with the head extended, and the endotracheal tube is partially withdrawn to allow an endoscope to be passed into the trachea. A small introducer needle is inserted percutaneously between the second and third tracheal rings and visualised endoscopically as it enters the trachea. A metal guide wire is then passed through this needle into the trachea and pulled upwards and out through the mouth. The existing tubes are then temporarily replaced with a narrower ventilation tube for the remainder of the procedure. There are variations in this part of the technique: for example the guide wire may be fed through the distal end of the endotracheal tube or a rigid tracheoscope and recovered at the tube connector.
3.2 The guide wire is attached to a special tracheostomy device consisting of a flexible plastic cone with a pointed metal tip, joined to an armoured tracheal cannula. The tracheostomy device is then drawn back through, in turn, the oral cavity, the oropharynx, the larynx, the trachea and finally out to the surface of the neck, through the small stoma created by the introducer needle. Traction is applied to the guide wire with one hand, and counter pressure to the neck with the other hand. The cone is then separated from the tracheostomy tube, which is rotated 180° so the open end of the tube faces down towards the carina and bronchi. Correct placement of the tracheostomy tube is confirmed by auscultation of the lungs and endoscopy.