Surgical Tips for Tracheostomy

1. Always try to have a surgical or Anesthetist colleague with you who understand the airway. Assistant has an important role in performing tracheostomy.
2. Choose a good pair of right angle retractor. Hold the retractor parallel to floor and try to lift soft tissues so that the blunt dissection of underlying strap muscles becomes easier.
3. Give Subcricoid incison so that tracheal stoma may be created at 2nd or 3rd tracheal ring level. Making a low incision will increase the depth of stoma and normal tracheostomy tube will prove to be shorter.
4. Try to dissect the pretracheal fascia as this will prevent the formation of surgical emphysema.
5. Secure a single knot at the nape. Do not make flower knot. A knot placed on lateral side of neck may cause vasovagal phenomenon. 
6. For tracheostomy, three things are must: Proper light, proper position of patient, good suction. Suction tip should be cut because a single hole sucks the tracheal secretions fast when it matters most and you have less time. In prolonged intubation cases, so much thick secretions are piled up that you actually need stronger suction.
7. In Adults, I give two parallel horizontal incisions over trachea beside the tracheal ring and then held that piece in tissue forcep and then complete the two vertical cuts with knife to take the cut piece with Alley's forceps. 
8. Nurse should be instructed to monitor the tracheostomy tube pressure and it should below 25 (below capillary pressure).