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Tracheostomy

This book discusses the indications, procedure, complications and post operative care of Tracheostomy. Even though this is  a commonly performed life saving procedure, its entire history of evolution makes an interesting reading.  Every Otolaryngologist should be really confident in performing this life saving procedure.  It only this procedure was commonly performed during the second world war lots of lives could have been saved.


Tracheostomy tube in situ


               By

Prof Dr. Balasubramanian Thiagarajan

Site: Otolaryngology Tutorial
Course: Otolaryngology Tutorial
Book: Tracheostomy
Printed by:
Date: Wednesday, 22 May 2019, 3:42 PM

1. Introduction

Tracheostomy is defined as a surgical formation of opening into the trachea through the neck to allow passage of air. “Merrium Webster dictionary”. Tracheostomy could be temporary or permanent. Permanent tracheotomy is usually performed after total laryngectomy. This process involves exteriorizing the trachea to the skin of the neck, thereby producing a fistula or permanent opening. This permanent opening is also known as a tracheostoma.


Great many lives have been saved by timely tracheostomy. In fact this surgery happens to be one of the oldest known surgical procedures performed on humans. History is replete with instances where this procedure has been dramatized.


2. History of Tracheostomy

As mentioned above tracheostomy happens to be a old surgical procedure. Description of this procedure could be seen in old Egyptian tablets dating back to 3600 BC. Asclepiades of Persia has been credited with the first tracheostomy way back in 100 BC. The famous warrior Alexander is known to have performed tracheostomy on his soldier in order to save his life. This happened during one of the drinking binges following a victory. A soldier had aspirated a mutton piece following which started chocking. Alexander the great famously used his sword to open up the neck so that he could start breathing again. Mention about tracheostomy procedure could be found in ancient Hindu texts written in 2000 BC.


Hippocrates (460-377 BC) knew pretty well the disastrous effects of carotid artery injury. He hence criticized the procedure to be too dangerous to be practiced. Aretaeus of Cappadocia (today’s Turkey) condemned this procedure because the infection that followed the procedure was nearly always fatal.


The first properly documented tracheotomy was performed by Antonio Musa Brasavola of Italy in 1546. Ir was performed successfully on a patient who was suffering from laryngeal abscess.


George Martin of Scotland was the first Briton to carry out this procedure successfully. He also recommended the use of double lumen tube. He also documented that the wound closed normally and spontaneously when the tracheostomy tube as withdrawn.


The first tracheostomy in a child was first performed by Caron in 1766. He performed this procedure to remove a foreign body (I.e a bean) from the child’s airway. His pupil Trousseau had performed nearly 200 tracheotomies on children with diphtheria. It was Trousseau who brought legitimacy to this procedure as a life saving one. He was also the first to design a retractor to open up the soft tissue before trachea could be exposed. This dilator is known as Trousseau’s dilator.


This procedure became rather common during the latter half of 19th century. It was usually performed at a high level. This gave rise to may complications like subglottic stenosis etc. It was Jackson in 1921 who standardized the procedure with clear cut documented indications for the surgery.


Lots of literature in 20th century was generated on this topic which centered around recognition of clinical signs of laryngeal obstruction, development of safe surgical technique and after care of the patient.


Galloway 1943 proposed another use for tracheostomy – To clear the airway off its secretions. He commonly performed this surgery on patients with Bulbar polio who suffered from aspiration of their own oral secretions. This turned out to be an eye opener for almost all surgeons. He has identified another use for this procedure.


Carter and Giuseffi advocated this life saving procedure for patients with badly crushed chest. Many patients owe their lives to them because it really tilted the balance of survival in favor of the patient. Many a life could have been saved during the second world war if only this procedure was commonly performed.


Another indication for tracheostomy got evolved fairly late in Scandinavia. In 1952 – 53 there was a polio epidemic there. Bulbar polio was nearly fatal because of respiratory arrest. Tracheostomy was performed in these patients to take control of their airway. Positive pressure ventilation via tracheostome was practiced those days. Norlander advocated early tracheostomy in these patients so that air way could be maintained better and more effectively.


The entire history of tracheostomy could be summarized under three headings:


1. Ancient period – The procedure fraught with many risks. Many surgeons did not undertake this procedure because of sheer fear of losing the patient in the process. This phase covered nearly 3000 years (1500 BC to 1500 AD). Tracheostomy was performed in Greece way back in 3600 BC as evidenced by neck wounds in Egyptian mummies. Rig Veda the Hindu text describes spontaneous healing of tracheostomy wound. Despite the warnings of Hippocrates Antyllus advocated tracheostomy in children with adeno tonsillar hypertrophy (second century AD). He was also the one who suggested that this procedure is best performed between the second and third rings of trachea. 20 years later Galen described the anatomy of larynx in detail.


2. Period of Acceptance – During this phase the entire procedure gained acceptance as a life saving procedure. It was accepted as a last life saving method in certain conditions. It was George Martin who developed a double cannula tracheostomy tube. He suggested that the inner tube can be safely removed and cleaned and reinserted.


3. Period of rationalization – This period started from 1965. The entire procedure got standardized with clear cut indications, ideal surgical procedure to be followed and post operative care that should be provided. It was during this phase that the entire procedure was considered to be an acceptable risk and many surgeons practiced it without hesitation.


    Antonio Musa Brasavola

3. Indications of tracheostomy

The advent of intensive care units and presence of ventilators during 1950s changed the status of tracheostomy from a life saving emergency procedure to that of a prolonged life supporting procedure.



"The main indication of tracheostomy is that when the surgeon thinks about it" (Mosher).


1. In upper air way obstruction (obstruction above the level of larynx). Trachesotomy is indicated in all cases of upper airway obstruction irrespective of the cause as an emergency life saving procedure. It is also indicated in impending upper airway obstruction as in the case of angioneurotic oedema of larynx.


2. For assisted ventilation: In comatose patients who donot have the required respiratory drive airway can be secured by performing a tracheostomy and the patient can be connected to a ventilator for assisted ventilation.


3. For bronchial toileting: Chronically ill patients who donot have sufficient energy to cough out the bronchial secretions may have to undergo tracheostomy with the primary aim of sucking out the bronchial secretions through the tracheostome.


4. In cases of prolonged intubation: tracheostomy will have to be performed to prevent subglottic stenosis.




General indications for tracheostomy include:


1. Congenital anomaly compromising airway like hypoplastic larynx, vascular web etc


2. Foreign bodies in upper airway that cannot be dislodged with Heimlich or other supportive maneuvers


3. Supra glottic / glottic pathology ( infections, neoplasm, bilateral vocal cord paralysis)


4. Neck trauma causing severe injuries to thyroid / cricoid cartilages, hyoid bone or great vessels


5. Subcutaneous emphysema that could endanger the airway


6. Facial bone fractures that could endanger airway


7. Upper airway angioneurotic oedema or oedema of upper airway due to burns, infection etc


8. Prophylaxis before extensive head and neck surgical procedures


9. Severe sleep apnoea not amenable to continuous positive pressure air way pressure


10. Tracheostomy needs to be performed if the patient needs to be on prolonged ventilation


11. To clear air way secretions in patient with poor cough reflex


12. Council for critical care of the American College of chest physicians recommend tracheostomy in patients who require mechanical ventilation for more than 7 days (prolonged intubation).

4. Advantages of tracheostomy

1. The procedure permanently secures the airway.


2. The anatomical dead space is reduced.


3. Tracheostomy byepasses the upper airway and hence it is useful in upper airway obstructions.


4. Suction can be applied through the tracheostome and bronchial secretions can hence be cleared.


5. If portex tube is used as tracheostomy tube it can be connected to a ventilator thus assisting the process of ventilation. The silastic tracheostomy tubes should not be sterilised using ethylene oxide because it has the ability to retain some to the gas for a period up to one week. The slow liberation of toxic bye products such as ethylene glycol and ethylene chlorhydrin can cause severe mucosal damage. These tubes have reduced the frequency of tracheostomy tube changes.

6. Nebulized medications (sprays, mists) and Oxygen can be effectively delivered through the tracheostome

7. Can be resorted to if long term ventilation of a patient is desired.  Long term ventilation on an intubated patient can cause subglottic stenosis.  This could be due to the irritation caused by the endotracheal tube to the mucosa lining the cricoid cartilage.  The vibrations of the ventilator could be transmitted by the endotracheal tube causing further mucosal trauma in the subglottic region.

8. Use of cuffed tracheostomy tubes helps in preventing aspiration because it effectively seals the air way from pharyngeal contents

5. Disadvantages of tracheostomy

1. It is a surgical procedure and hence has morbidity and mortality rates associated with surgical procedures.


2. The tracheostomy tube will have to be cleaned periodically.


3. During early phases periodical suction must be applied hence hospital support is a must.


4. The patient may not be able to use the voice. Some tracheostomy tube like the Fuller's metal tube may have a speaking valve which could help the patient to speak, the patient must get used to plugging the hole while speaking.


5. Decanulation is a complicated procedure.


6. Since the upwards and downwards movement of larynx is important for swallowing, patients with tracheostomy have swallowing difficulties because this movement is restricted


7.  Leaving behind a tracheostomy tube for long duration may cause the tube to detach from the neck and become an airway foreign body

6. Types of Tracheostomies



1. Temporary tracheostomy:

    This life saving procedure is usually performed as a temporary measure to secure the airway while performing complex head and neck surgical procedures which involve airway sharing with the anesthetist.  Securing the airway electively also helps in preventing post-operative airway obstructions. 

Indications:

a.     Prior to any complex head and neck surgeries where airway is under threat

b.    To tide over problems caused by impending airway obstruction due to oedema involving mucosal lining of supraglottis / glottis / subglottis areas.

c.     When airway is threatened due to the presence of Foreign bodies

d.    In ICU setting where the patient needs to be kept on ventilator for more than 7 days.

e.     In patient’s with altered sensorium / coma to keep the lower airway free of secretions

      In this procedure decannulation is ideally performed within a span of 2 weeks.  A small modification in the surgical procedure where in instead of removing a small portion of anterior tracheal wall cartilage an inferior based cartilage flap (Bjork flap) is created.  This flap can be anchored to the skin of the stoma to keep the stoma open.  When it is time to decannulate all that needs to be done is to remove the stay suture anchoring the cartilage flap to the skin of the stoma.  The flap will fall back on to the anterior wall of the trachea closing off the stoma.

In 1952 Bjork created this inferior based cartilage flap through the 2nd 3rd and 4th tracheal rings and anchored it to the stomal skin using silk 1

Bjork’s flap can safely be created only in elective tracheostomies and not under emergency setting.  This flap can be created with minimal complications but needs some amount of patience on the part of the operating surgeon to perform. 

Contraindications for performing Bjork’s flap:

1.    In pediatric tracheostomies.  The amount of cartilage present in the trachea of children is so less that adjacent vital structures could well be damaged when this flap is attempted.

2.    This procedure is best avoided when tracheostomy is performed to secure air way in patients with laryngeal malignancies because it is usually performed as an emergency procedure.

3.    Ideally not performed in an irradiated neck because the skin would be thickened and the tracheal cartilage would have undergone fibrotic changes.  Any attempt to create cartilage flap in these patients would invariably result in a failure.

4.    In obese patients the neck is short and it would be difficult to create a Bjork flap of sufficient size 2.

5.    If a surgeon is alone performing tracheostomy then Bjork’s flap is ideally avoided

Surgical technique:

This procedure can be performed either under local anesthesia or general anesthesia.  Ideally any neck surgery should be performed under good lighting conditions.  The same goes with tracheostomy also.  Different sized tracheostomy tubes should also be available.

Position:

Supine with neck extended by placing a small sandbag under the shoulder blades of the patient.  The shoulders should be symmetrically placed to ensure that the trachea stays in the midline always.  The area where surgery is going to be performed should be painted with povidone iodine liberally and the patient draped.

Key landmarks should be marked over the skin.  They include Hyoid bone, thyroid cartilage and cricoid cartilage.  Transverse skin incision is usually placed at half way between the lower border of cricoid cartilage and the supra sternal notch.  This area is infiltrated with 2% xylocaine mixed with 1 in 100000 adrenaline.  About 5 ml of the local anesthetic can be used.  Some amount of infiltration should also be given along the medial border of lower third of sternomastoid muscles on both sides.

Before start of surgery the patient should be premedicated with sedatives and anxiolytics.  This will ensure better co-operation on the part of the patient.

The incision is usually transverse in elective tracheostomy and vertical in emergency setting.  The incision is given at the half way mark between the lower border of cricoid cartilage and the suprasternal notch.  The incision is usually 3 cm long and may even be extended if needed.  The skin and subcutaneous fat are dissected out and are held away from the field by using retractors.  Langenbeck retractors are used for this purpose.  If the surgeon is performing the surgery alone then self-retaining retractor is ideal.



Image showing Langenbeck retractor



Self retaining retractor

Blunt dissection is performed along the midline of neck pushing away the strap muscles from midline.  The isthmus of thyroid gland comes into the field when the soft tissues and muscles are retracted from the midline.  The isthmus is divided and tied using diathermy and silk.  The anterior wall of trachea becomes visible.  Trachea can easily be identified by its rings.  The pretracheal fascia should be peeled away from the anterior wall of trachea. 

At this stage it would be useful to identify the cricoid cartilage to assess where exactly trachea should be opened.  Tracheostomy is usually performed between the 3rd and the 4th tracheal rings.  A small amount of 2% xylocaine with 1 in 100000 adrenaline is infiltrated into the trachea to suppress the cough reflex if the surgery is being performed under local anesthesia.

In order to perform Bjork’s flap, the tracheal incision should be inverted U shaped one.  The transverse portion of the U incision is made in the intercartilagenous zone between the second and third tracheal cartilages.  This step is usually performed using a 15 blade.  The downward vertical incisions are then performed ideally using scissors.  The vertical limbs of the incision go through the 3rd and 4th tracheal rings.  The first tracheal ring should be avoided because of the fear of subglottic stenosis. 

The cartilage flap is stitched to the subcutaneous tissue.  Suction is applied through the tracheostome to clear the secretions.  Appropriate sized portex cuffed tracheostomy tube is introduced.  The tube is anchored by tying the tape.  Cuff is inflated.









Figure showing Bjork’s flap anchored to the skin of stoma


The main advantage of Bjork’s flap tracheostomy is during post-operative management of these patients.  The tracheostomy tube can easily be removed cleaned and replaced without fear of airway occlusion.  There is virtually no chance of false track creation while reinserting the tracheostomy tube after cleaning it.


During decannulation the fistula may close rather slowly which is in fact beneficial in some patients in weaning them out of the tracheostomy.

 

Indications include prophylactic and therapeutic indications.

 

Prophylactic indications:

 

After abdominal / thoracic surgical procedures the cough reflex is blunted predisposing to development of pneumonia. A mini tracheostomy in these patients will help in preventing pneumonia.

 

Therapeutic indications:

 

To clear sputum in patients with COPD, or in other conditions where there is sputum retention.

 

Contraindications:

 

1. Must be performed only by trained personal

 

2. If landmarks in the neck are not clear then this procedure should not be performed.

 

3. Should not be performed under extreme airway emergencies

 

 




2. Permanent or end tracheostomy :

     This is done in patients who have underwent total laryngectomy.  This is also known as the end tracheostomy.  Here after the removal of larynx, the proximal end of trachea is anchored to the skin.  Patient needs to live the entire duration of the life by breathing through the tracheostome.

Major draw back in these patients is the loss of speech.  Voice rehabilitation procedures need to be performed in them in order at least to restore partial speech function.


3. Mini tracheostomy:

This procedure is also known as cricothyroidotomy. This is in fact one type of cricothyroidotomy.  This is commonly performed as an emergency procedure to secure the airway as well as to prevent aspiration.  Cricothyroid membrane is incised through a vertical incision and the tracheostomy tube is introduced through it to secure the airway.  In mini tracheostomy a small cannula is passed through the incision made in the cricothyroid membrane.  A separate kit known as mini tracheostomy kit is available for this very purpose.  This procedure was popularized by neurosurgeons.  It involves using a mini tracheostomy kit.

 The kit contains:

1.     A special scalpel

 

2.     Canula

 

3.     Obturator

 

4.    Suction tube

 

5.    A tape to anchor the tube

 

     No sedation may be needed for this procedure as this would invariably be performed    in dire emergency settings.  More over patients would already be hypoxic and hence sedation is contraindicated for fear of respiratory depression.  To perform this procedure an assistant is always needed.  This is not a procedure to be performed by a single surgeon.  An assistant is necessary to hold the head steady as these patients are invariably restless due to hypoxia.  This is a bed side procedure and can be performed while the patient is supine in the bed.  The head of the patient is usually inclined up.  It is ideal to place a pillow under the shoulder blades of the patient while the head is stretched over the back of the pillow.  This position keeps the trachea stretched in the midline preventing its lateral movement.  The oxygen mask is fixed to the patient’s face upside down in order to avoid the tubing coming in the way during surgery.

The thyroid cartilage is identified next.  It is usually easy to identify it in males than in females.  The cricoid cartilage would be just below the thyroid cartilage.  If there is any doubt it is better to go low into the trachea than high above the level of vocal cords. 

Risk of injury to isthmus is a strong possibility.  If a guide wire and dilator is used then this would be a minimal problem only.  If knife is used then there is a distinct possibility of bleeding from injury to isthmus of the thyroid gland.

The thyroid cartilage is fixed between two fingers.  It ensures that the trachea is kept in position till the cannula is inserted.  Local anesthetic (2% xylocaine with 1 in 100000 adrenaline) is injected over the site of incision.  The needle can be inserted through the cricothryoid membrane and a small amount of the anesthetic can be infiltrated.  Patient should start coughing if the needle is in the correct position.  A vertical incision is made over the skin long enough to ensure that there is no resistance at the level of skin.  This will ensure better palpation of the trachea.  A guarded knife can be used to cut through the skin subcutaneous tissues and the cricothyroid membrane.  A dilator can be introduced to dilate the opening and the tracheostomy tube can be introduced and actually be guided by the dilator.

In Seldinger’s technique a special needle known as the Tuohy needle is used to perforate the cricothyroid membrane instead of the knife.  This needle is introduced through the skin incision at right angles to that of the trachea.  A pop could be felt as the needle passes through the anterior wall of the trachea.  The needle is kept still and a syringe filled with water is connected to it and aspirated to ensure that the needle is inside the trachea.  If unsure it is best to incise the cricothyroid membrane with a knife and dilate it using a mosquito forceps. 

The syringe is removed while the needle is still inside the trachea.  A guide wire (using its flexible end) is passed through the needle into the trachea.  Ideally before this procedure it is better to point the needle towards the carina.  A dilator is passed over the guide wire repeatedly to dilate the opening.  Then tracheostomy tube is introduced using the guide wire to guide it into position.



 



4. Percutaneous tracheostomy:

Since the advent of open tracheostomy efforts were made to devise a procedure which will enable access into the trachea without a surgical incision or a minimal surgical incision. Percutaneous tracheostomy was devised with just this purpose in mind.

Advantages of percutaneous tracheostomy:

 

1. It is a simple procedure

 

2. Very easy to perform under emergency situations

 

3. Can be performed easily on the bed side

 

4. Can be performed by paramedics

 

Evolution of percutaneous tracheostomy:

 

The first tracheostomy technique that did not require neck dissection was first described by Sheldon in 1957. He used a specially designed slotted needle to blindly enter the tracheal lumen. This needle served as a guide for the introduction of a stillete and a metal tracheostomy tube.

 

In 1969 Toyee refined this technique making it incisional rather than dilational. In this technique after the trachea was cannulated using a needle, the tracheostomy tube was loaded on to a stiff wire boogie that contained a small recessed blade. This boogie along with the tracheostomy tube was advanced through the needle tract thereby placing the tracheostomy tube inside the trachea. This procedure was fraught with risks and para tracheal insertions occurred commonly and hence did not become popular.

 

In 1985 Ciaglia perfected the technique of percutaneous tracheostomy which is currently gaining popularity. He named this procedure dilational subcricoid percutaneous tracheostomy. (PDT). This technique has undergone three significant modifications:

 

1. The tracheal interspace for cannulation has been moved down by two rings caudal to the cricoid cartilage. This was done to prevent the development of subglottic stenosis.

 

2. Routine use of fibreoptic bronchoscopy has been advocated.

3. The use of single beveled dilator has been substituted by the use of multiple dilators.

 

Ciaglia's procedure:

 

The vital signs of the patient are continuously monitored during the procedure. The patient is ventilated with 100% oxygen during the whole procedure. The patient is sedated using a narcotic analgesic, and often a non depolarising neuromuscular blocker is used. The neck of the patient is extended to bring up the trachea closer to the skin. The vertex of the patient is properly supported.

 

A 2 cm skin incision is located at the level of 1st and the 2nd tracheal rings. The wound is then dissected bluntly using artery forceps. The existing endotracheal tube is then slowly withdrawn to a level just above the first tracheal ring, the needle is then inserted through the incision to penetrate the trachea between the second and the third tracheal rings. The J tipped guide wire is inserted through the needle till it hits the level of carina. The needle is then withdrawn. Bevelled plastic dilators are introduced over this guide wire and the opening is dilated to create a tracheostome. When the dilatation is adequate a special tracheostomy tube is inserted over the guide wire. The dilators can be used as obturators. In properly performed precutaneous tracheostomy the tracheostomy tube will pass through the isthumus of the thyroid, there will not be any significant bleeding because the procedure is purely dilatational.

 

Paul's modification of Ciaglia technique:

 

This modification was introduced in 1989. Paul advocated the use of fibreoptic bronchoscope through the endotracheal tube to facilitate percutaneous tracheostomy.

 

The advantages of this modification are:

 

1. Use of bronchoscope allows for correct placement of tracheostome.

 

2. It ensures that the guide wire is introduced in a midline position.

 

3. It prevents damage to posterior tracheal wall during introduction of needle.

 

4. It helps in video recording the whole procedure for instructional purposes.

 

The major disadvantages of this modification are:

 

1. It involves more time.

 

2. More trained personal and special equipment are needed.

 

3. The procedure is more expensive.

 

To reduce the operating time a single curved dilator (Blue rhino dilator) is utilized instead of multiple dilators. Since this dilator is soft and has a more physiologic curvature it does not cause extensive damage to the soft tissues and the tracheal walls.

Rapitrach technique: This was first introduced in 1989 by Sachachner with an intention in facilitating a rapid tracheostomy. A special Rapitrach dilator was used. A rapitrach has two sharp blades designed in such a way that it slides over the guide wire and an opening is made when it is dilated. This procedure had a high incidence of damage to the membranous posterior tracheal wall. To avoid this complication in 1990 Griggs used custom-made forceps known as the Howard Kelly forceps. The tip of the forceps can be opened to create a tracheostome. In fact, in all these methods the basic steps are the same but for modifications in the dilatation technique.

Translaryngeal tracheostomy: This was first described by Fanconi etal. The major aim of this procedure is to prevent damage to the posterior membranous wall of the trachea. The dilatation in Ciaglia technique is directed in a downward direction causing significant anteroposterior compression of the tracheal wall.


 Sometimes this compression is sufficient to cause rupture of the membranous posterior tracheal wall. In this technique this excess anteroposterior pressure is avoided since the tracheostomy tube is pulled upwards through the larynx in an inside out manner. The procedure is similar to Ciaglia technique till the introduction of a guide wire through the first and the second tracheal interspaces. The similarity ends here. The guide wire is passed through the needle into the larynx in a retrograde fashion, in fact it traverses coaxially alongside the endotracheal tube till it reaches the oral cavity from where it is pulled out using a Magill's forceps. The aim of the next step is to create a room for the tracheostomy tube to traverse the larynx since an endotracheal tube is already in position. To achieve this the existing endotracheal tube in position is replaced with a smaller endotracheal tube using the same guide wire as a guide. The J tip (oral cavity end) of the guide wire is then attached to a special trocar and tracheostomy tube assembly. The guide wire is pulled through its neck end. This pulls the trocar along with the tracheostomy tube through the larynx into the trachea. Here excessive tension to the posterior tracheal wall is avoided. When the trocar causes tenting of skin in the neck a small incision is made over this tenting and the trocar is delivered out along with the tracheostomy tube. The endotracheal tube is removed, and the tracheostomy tube is anchored in place.

Since these procedures involve an already intubated patient it calls for excellent coordination between the surgeon and the anesthetist.

 

Routine pre-operative ultrasound examination of the neck is a must because it will identify the site of an unusually large inferior thyroid veins which could cause troublesome bleeding during the procedure.

 

Contraindications:

 

1. A patient already in intense stridor.

 

2. Laryngeal malignancies

 

3. Short neck individuals


4. When proper trained personal is not available

 

5. Large thyroid gland

 

6. When ultrasound reveals an abnormally large inferior thyroid vein.




Figure showing Blue Rhino dilator



 

Figure showing Rapitrach dilator




5. Cricothyroidotomy


6. High tracheostomy


7. Low tracheostomy


8. Elective tracheostomy