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Contraindications to tracheostomy

Contraindications to tracheostomy
Absolute*
  • Cellulitis anterior neck
  • Absence of cervical trachea
  • Uncorrectable bleeding diathesis (eg, International Normalized Ratio >2.0, platelets <50,000 × 109/L)
Relative*
  • Hemodynamic instability
  • Severe hypoxemia (eg, positive end-expiratory pressure [PEEP] >12 cm H2O)
Relative contraindications for percutaneous tracheostomy
  • Morbid obesity and/or short neck with inability to identify and palpate trachea
  • Vascular structures such as a high-riding innominate or thyroid internal mammary artery (on palpation or ultrasound)
  • Gross distortion of the neck from hematoma, tumor, thyromegaly, or scarring
  • Severe tracheomalacia with cartilage destruction
  • Inability to safely extend the neck (eg, cervical fusion, rheumatoid arthritis, or other causes of cervical spine instability)Δ
  • Prior complex tracheal surgery (eg, tracheoplasty, tracheal resection, and reconstruction; previous tracheostomy is not a contraindication)
  • Children <15 years
  • Patients requiring emergency airway◊
* These contraindications apply to both percutaneous and surgical approaches.
¶ In these cases, a surgical open approach is suggested.
Δ Some patients in this category who have a long neck may be able to undergo a percutaneous tracheostomy placement, but only if neck extension is considered safe.
◊ While cricothyrotomy is considered the preferred approach during emergencies, percutaneous tracheostomy is an alternative when performed by an experienced operator.
Graphic 135093 Version 1.0