Tracheostomy is usually performed between the tracheal rings of?

RUHS, Jaipur, PB B.Sc Nursing Entrance-2018

Medical & Surgical Nursing

Easy

Appeared in: RUHS, Jaipur, PB B.Sc Nursing Entrance-2018

Explanation

The standard surgical site for a tracheostomy is between the second and third tracheal rings, as confirmed by nursing and anatomy textbooks.
This location is considered the safest because it provides an adequate distance from the cricoid cartilage located superiorly, which helps prevent the complication of subglottic stenosis (narrowing of the airway below the vocal cords).
This site is also superior to the innominate artery and the apex of the lungs, reducing the risk of catastrophic hemorrhage or pneumothorax during the procedure.

Option A: This site is too low. A tracheostomy between the 4th and 5th rings carries a significant risk of injuring the innominate artery or the pleura, leading to life-threatening bleeding or a collapsed lung.
Option B: While closer to the ideal site, the 3rd and 4th rings are often covered by the isthmus of the thyroid gland, which would need to be retracted or divided, complicating the procedure. It is also closer to the innominate artery than the 2nd-3rd ring space.
Option D: This is considered a 'high' tracheostomy and is generally avoided. Placing the incision between the 1st and 2nd rings poses a high risk of damaging the cricoid cartilage, the only complete cartilaginous ring in the airway. Damage here can lead to severe, long-term subglottic stenosis.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Anatomical landmarks for tracheostomy as background academic context rather than a clinical decision trigger.
Nurses must be aware of the correct anatomical placement to anticipate and monitor for potential complications. A high placement can lead to voice changes or airway narrowing, while a low placement increases the risk of major bleeding.
A critical nursing responsibility is ensuring emergency equipment is at the bedside for any patient with a tracheostomy. This includes a spare tracheostomy tube of the same size, one a size smaller, an obturator, and suction equipment. Accidental decannulation is a medical emergency.
What if? If a patient with a new tracheostomy (less than 7 days old) accidentally coughs the tube out, the nurse's first action is to call for help (e.g., activate the emergency response team) and maintain the patient's airway, possibly by using a bag-valve-mask over the mouth and nose. Do not attempt to blindly reinsert the tube, as this can create a false passage.

How to Approach the Question

This is a factual recall question asking for a specific anatomical landmark related to a common surgical procedure.
First, identify the key terms in the question: 'Tracheostomy' and 'tracheal rings'.
Recall the basic anatomy of the anterior neck, including the larynx (voice box), cricoid cartilage, and the trachea (windpipe) with its C-shaped rings.
Think about the goal of the procedure: to create a secure airway while avoiding damage to surrounding critical structures.
Consider the structures to avoid: the cricoid cartilage (superiorly) and major blood vessels like the innominate artery (inferiorly).
The ideal location must be a 'safe zone' between these structures. This corresponds to the middle part of the cervical trachea.

Concept Tested & Keywords

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E6 Nursing Fundamentals Taylor p. 736-738

E6 Anatomy Applied Ashalatha 4e p. 98-100