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Risks/complications
As with most other surgical procedures, some cases are more difficult than others. Surgery on children is more difficult because of their smaller size. Difficulties such as a short neck and bigger thyroid glands make the trachea hard to open. There are other difficulties with patients with irregular necks, the obese, and those with a large goitre.

Potential complications[edit]
The many possible complications include hemorrhage, loss of airway, subcutaneous emphysema, wound infections, stomal cellulites, fracture of tracheal rings, poor placement of the tracheostomy tube, and bronchospasm.

Early complications include infection, hemorrhage, pneumomediastinum, pneumothorax, tracheoesophageal fistula, recurrent laryngeal nerve injury, and tube displacement. Delayed complications include tracheal-innominate artery fistula, tracheal stenosis, delayed tracheoesophageal fistula, and tracheocutaneous fistula. (Yu Current Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery, 3e)

A 2013 systematic review (published cases from 1985 to April 2013) studied the complications and risk factors of percutaneous dilatational tracheostomy (PDT), identifying major causes of fatality to be hemorrhage (38.0%), airway complications (29.6%), tracheal perforation (15.5%), and pneumothorax (5.6%). A similar systematic review in 2017 (cases from 1990 to 2015) studying fatality in both open surgical tracheotomy (OST) and PDT identified similar rates of mortality and causes of death between the two techniques. (Klemm)

Hemorrhage[edit]
Hemorrhage is rare, but the most likely cause of fatality after a tracheostomy. It usually occurs due to a tracheoarterial fistula and most commonly manifests between 3 days to 6 weeks after the procedure is done. Fistulas can result from incorrectly positioned equipment, high cuff pressures causing pressure sores or mucosal damage, a low surgical trachea site, repetitive neck movement, radiotherapy, or prolonged intubation.

A potential risk factor identified in a 2013 systematic review of the percutaneous technique was the lack of bronchoscopic guidance. Use of the bronchoscope can help with proper placement of instruments and better visualization of anatomical structures. However, this can also be dependent on the skills and familiarity of the surgeon with both the procedure and the patient's anatomy.

Airway complications
There are a multitude of potential complications related to the airway. Main causes of mortality during PDT include dislodgment of the tube, loss of airway during procedure and misplacement of the tube. (Simon) One of the more urgent complications include displacement or dislodgment of the tracheotomy tube, either spontaneously or during a tube change. Although uncommon (< 1/1000 tracheostomy tube days), the associated fatality is high due to the loss of airway. (Raj) Due to the seriousness of such a situation, individuals with a tracheotomy tube should consult with their healthcare providers to have a specific, written, emergency intubation and tracheostomy recannulation (reinsertion) plan prepared in advance.

Long-term complication- tracheal stenosis
Tracheal stenosis, otherwise known as an abnormal narrowing of the airway, is a possible long term complication. The most common symptom of stenosis is gradually-worsening difficulty with breathing (dyspnea). However incidence is low, ranging from 0.6 to 2.8% with increased rates if major bleeding or wound infections are present. A 2016 systematic review identified a higher rate of tracheal stenosis in individuals who underwent a surgical tracheostomy, as compared to PDT, however the difference was not statistically significant. (Dempsey)

Complication rates[edit]
A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 10–15% and a procedural mortality of 0%, which is comparable to those of other series reported in the literature from the Netherlands and the United States. A 2013 systematic review calculated procedural mortality to be 0.17% or 1 in 600 cases. Multiple systematic reviews identified no significant difference in rates of mortality, major bleeding, or wound infection between the percutaneous or open surgical methods. (Dempsey)

Specifically a 2017 systematic review calculated the most common causes of death and their frequencies, out of all tracheotomies, to be hemorrhage (OST: 0.26%, PDT: 0.19%), loss of airway (OST: 0.21%, PDT: 0.20%), and misplacement of tube (OST: 0.11%, PDT: 0.20%). (Klemm)

A 2003 American cadaveric study identified multiple tracheal ring fractures with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases. The comparative study above also identified ring fractures in 9 of 30 live patients while another small series identified ring fractures in 5 of their 20 patients. The long term significance of tracheal ring fractures is unknown.[citation needed]

Open surgical tracheotomy (OST)
The typical procedure done is the open surgical tracheotomy (OST) and is usually done in a sterile operating room. The optimal patient position involves a cushion under the shoulders to extend the neck. Commonly a transverse incision is made two fingerbreadths above the sternal notch. Alternatively, a vertical incision can be made in the midline of the neck from the thyroid cartilage to just above the suprasternal notch. Skin, subcutaneous tissue, and strap muscles (neck muscles) are retracted aside to expose the thyroid isthmus, which can be cut or retracted upwards. After proper identification of the cricoid cartilage and placement of a tracheal hook to steady the trachea and pull it forward, the trachea is cut open vertically, either through the space between cartilage rings or vertically across multiple rings (cruciate incision). Occasionally a section of a tracheal ring may be removed to make insertion of the tube easier. Once the incision is made, a properly sized tube is inserted. The tube is connected to a ventilator and proper ventilation and oxygenation is confirmed. The tracheotomy apparatus is then attached to the neck with tracheotomy ties, skin sutures, or both. (Yu, Zollinger)

Society and culture
Notable individuals who have or have had a tracheotomy include Stephen Hawking, Christopher Reeve (actor). (http://www.chrisreevehomepage.com/biography.html)

In popular media
Across movies and TV shows, there are many situations where an emergency procedure is done on an individual's neck to re-establish an airway. The most common procedure is a cricothyrotomy (or "crike"), which is an incision through the skin and cricothyroid membrane. This is often confused or misnamed as a tracheotomy (or "trach") and vice versa. However, they are quite different based on location of the opening and length of time the alternate airways is needed.

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