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

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Contraindications to tracheostomy