After the trachea has been intubated, a balloon cuff is typically inflated just above the far end of the tube to help secure it in place, to prevent leakage of respiratory gases, and to protect the tracheobronchial tree from receiving undesirable material such as stomach acid. The tube is then secured to the face or neck and connected to a T-piece, anesthesia breathing circuit, bag valve mask device, or a mechanical ventilator. Once there is no longer a need for ventilatory assistance or protection of the airway, the tracheal tube is removed; this is referred to as extubation of the trachea (or decannulation, in the case of a surgical airway such as a cricothyrotomy or a tracheotomy). For centuries, tracheotomy was considered the only reliable method for intubation of the trachea. However, because only a minority of patients survived the operation, physicians undertook tracheotomy only as a last resort, on patients who were nearly dead. It was not until the late 19th century, however, that advances in understanding of anatomy and physiology, as well an appreciation of the germ theory of disease, had improved the outcome of this operation to the point that it could be considered an acceptable treatment option. Also at that time, advances in endoscopic instrumentation had improved to such a degree that direct laryngoscopy had become a viable means to secure the airway by the non-surgical orotracheal route.
After one hour of apneic oxygenation through a needle cricothyrotomy, one can expect a PaCO2 of greater than 250 mm Hg and an arterial pH of less than 6.72, despite an oxygen saturation of 98% or greater. A more definitive airway can be established by performing a surgical cricothyrotomy, in which a 5 to 6 mm (0.20 to 0.24 in) endotracheal tube or tracheostomy tube can be inserted through a larger incision.Several manufacturers market prepackaged cricothyrotomy kits, which enable one to use either a wire-guided percutaneous dilational (Seldinger) technique, or the classic surgical technique to insert a polyvinylchloride catheter through the cricothyroid membrane. The kits may be stocked in hospital emergency departments and operating suites, as well as ambulances and other selected pre-hospital settings. Tracheotomy
Tracheotomy consists of making an incision on the front of the neck and opening a direct airway through an incision in the trachea. The resulting opening can serve independently as an airway or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe without the use of his nose or mouth. The opening may be made by a scalpel or a needle (referred to as surgical and percutaneous techniques respectively) and both techniques are widely used in current practice. In order to limit the risk of damage to the recurrent laryngeal nerves (the nerves that control the voice box), the tracheotomy is performed as high in the trachea as possible.