Open Surgical Tracheostomy
3160031601wRVU: 7.8 — Tracheostomy, younger than 2 years31603wRVU: 5.85 — Tracheostomy, emergency (transtracheal)31605wRVU: 6.29 — Cricothyrotomy (emergency surgical airway)
Respiratory failure requiring prolonged mechanical ventilation [/ airway obstruction / inability to wean from mechanical ventilation / head and neck cancer requiring airway protection]
Same
Open surgical tracheostomy
[Attending name], MD/DO
[Resident/PA name]
General endotracheal [/ local with sedation (bedside ICU)]
The patient is a [age]-year-old [male/female] with [diagnosis] who has required mechanical ventilation for [X] days with [failure to wean / anticipated prolonged intubation / upper airway obstruction not amenable to endotracheal intubation]. Tracheostomy was recommended to [facilitate weaning / improve patient comfort / enable long-term airway management]. The risks, benefits, and alternatives including percutaneous tracheostomy were discussed with the patient [/family/healthcare proxy], and informed consent was obtained.
The trachea was [midline / deviated to the [right / left]]. The thyroid isthmus was [thin and easily retracted / vascular and required division]. The cricoid cartilage was [palpable / obscured by overlying tissue]. The trachea was entered at the [second / third] tracheal ring. The endotracheal tube balloon was palpable in the proximal trachea and was withdrawn under direct visualization before tracheal entry.
The patient was positioned supine with a shoulder roll to extend the neck. The neck was prepped and draped in sterile fashion. The cricoid cartilage, thyroid cartilage, and sternal notch were palpated and marked.
A [2-cm] horizontal skin incision was made approximately [2 fingerbreadths] above the sternal notch, or at the level of the second tracheal ring. The subcutaneous tissue and platysma were divided with electrocautery. The strap muscles (sternohyoid and sternothyroid) were separated in the midline with blunt dissection and retracted laterally.
The thyroid isthmus was identified overlying the upper tracheal rings. The isthmus was [retracted superiorly with a ribbon retractor / divided between clamps and oversewn with [3-0 Vicryl] to expose the tracheal rings].
The pretracheal fascia was cleared from the [second and third] tracheal ring. The anesthesiologist was notified and the endotracheal tube balloon was deflated and withdrawn to above the planned entry site under direct visualization.
A tracheal hook was placed under the inferior margin of the [first] tracheal ring for superior traction. A [horizontal / vertical midline] incision was made through the [second and third tracheal ring cartilages] with a [#15 blade / heavy scissors]. [Bjork flap (optional, institutional preference): a U-shaped inferiorly-based flap was cut from the second ring and sutured to the inferior skin edge with [2-0 Prolene] to facilitate tube replacement and reduce accidental decannulation risk. Note: the Bjork flap carries only a weak evidence recommendation in adults per 2020 Korean tracheostomy guidelines and is not universally used.]
A [size 8 / size 6] cuffed tracheostomy tube [Shiley / Portex] was inserted into the trachea under direct visualization. The cuff was inflated and ventilation confirmed by [bilateral breath sounds / end-tidal CO2 waveform]. The endotracheal tube was removed by the anesthesiologist.
The tracheostomy tube was secured with [tracheostomy ties / sutures to the skin]. The wound edges were approximated loosely with [interrupted 3-0 nylon]. Sterile dressings were applied around the tube.
None
None
Minimal (less than 10 mL)
None
The patient was returned to the [ICU / PACU] with the tracheostomy in place on [mechanical ventilation / supplemental oxygen via trach collar]. Post-procedure chest X-ray confirmed tracheostomy tube position. First tracheostomy tube change performed at [72 hours / 1 week].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Respiratory failure, prolonged mechanical ventilation
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Open surgical tracheostomy
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General ETT [/ local with sedation]
INDICATIONS: .PTAGE-year-old .PTSEX, mechanical ventilation day ***, [failure to wean / prolonged ventilation / airway protection]. Risks discussed with [patient/family]. Consent obtained.
FINDINGS: Trachea midline. Thyroid isthmus ***. Entry at *** tracheal ring.
PROCEDURE:
Supine, shoulder roll, neck extended. Horizontal incision 2 fingerbreadths above sternal notch. Platysma divided. Strap muscles separated midline. Thyroid isthmus [retracted / divided and oversewn 3-0 Vicryl]. Pretracheal fascia cleared. ETT cuff deflated, tube withdrawn above entry site. Tracheal hook placed inferiorly on [first ring]. [Horizontal incision / vertical incision / Bjork flap] through [second/third] ring cartilage. Size *** cuffed trach tube inserted under direct vision. Cuff inflated. Bilateral breath sounds confirmed. ETCO2 confirmed. ETT removed. Tube secured with ties. Wound loosely approximated.
EBL: Minimal
SPECIMENS: None
COMPLICATIONS: None
DISPOSITION: [ICU/PACU]. CXR: tube position confirmed. First tube change at ***.
Signed: .ME, .MYDEGREE
.TODAYVariants
Bedside ICU Tracheostomy
The procedure was performed at the bedside in the ICU under [local anesthesia with sedation / propofol + fentanyl infusion]. A bronchoscope was available for confirmation if needed. Lighting was ensured with a portable headlight. The procedure proceeded as described. Bedside tracheostomy avoids the risk of transport for critically ill patients. Use the same CPT code (31600) regardless of location (OR vs. ICU).
Difficult Neck (Obesity, Prior Surgery, Short Neck)
Given [obesity / prior anterior cervical surgery / prior neck radiation / short bull neck / tracheal deviation], anatomic landmarks were obscured. Ultrasound was used to identify the tracheal midline and estimate depth. The incision was extended. [Dissection was carried through adipose tissue with electrocautery to reach the strap muscles.] The trachea was confirmed by aspiration of air with a needle before formal entry. A [longer cuffed adjustable-flange tracheostomy tube] was placed to accommodate the increased depth. Confirm tube position with flexible bronchoscopy after placement in difficult-neck tracheostomy.
Charting Tips
- Document endotracheal tube management at time of tracheal entry. The most dangerous moment in tracheostomy is tracheal entry — the cuff must be deflated and the ETT withdrawn before making the tracheal incision to avoid cutting the cuff or balloon. Document 'the ETT cuff was deflated and the tube was withdrawn to above the planned entry site under direct visualization before tracheal incision.'
- Document tube size, type, and confirmation of ventilation. Record the tracheostomy tube manufacturer, size (inner/outer diameter), cuffed vs uncuffed. Document confirmation of bilateral breath sounds and end-tidal CO2 waveform after insertion. These are required for nursing handoff and post-op management.
- Document thyroid isthmus management. Superior retraction of the isthmus is the preferred approach — division is reserved for when exposure of the target tracheal rings cannot be achieved with retraction alone. Studies show no significant difference in major morbidity between retraction and division, but retraction preserves thyroid vascularity. If divided, document hemostasis (oversewn with absorbable suture). Document which approach was used and why.
- Document tracheal entry level. Entry below the second ring risks subglottic stenosis; entry below the fourth ring risks innominate artery erosion. Document tracheal entry at the second or third ring, confirmed by direct visualization and counting from the cricoid.
Billing Tips
- Open surgical tracheostomy: 31600 (5.42 wRVU, 0-day global). Use for all elective or semi-elective open tracheostomies performed in the OR or ICU under direct visualization with formal tissue dissection. The 0-day global means post-op trach care, tube changes, and clinic visits are separately billable from the date of surgery.
- Percutaneous dilational tracheostomy (Ciaglia technique): 31614 (different code). Percutaneous technique uses serial dilators over a guidewire with bronchoscopic guidance; open technique uses direct surgical dissection. Document which technique was used — they are not interchangeable codes.
- Emergency tracheostomy: 31603 (5.85 wRVU, 0-day global). Use for emergent tracheostomy performed without the usual pre-operative preparation. Document the emergent indication (acute airway obstruction, failed intubation, trauma).
- Tracheostomy in patients younger than 2 years: 31601 (7.80 wRVU, 0-day global). The higher wRVU reflects the technical difficulty of pediatric tracheal anatomy.
- Cricothyrotomy: 31605 (6.29 wRVU, 0-day global). A cricothyrotomy is not a tracheostomy. It enters through the cricothyroid membrane, not the trachea. Use 31605 for emergent cricothyrotomy; planned conversion to formal tracheostomy at a later date uses 31600 as a separate billable procedure.