Intraoperative complications are lowest when performed by an experienced surgeon. Nonotolaryngologists are 9.1 times more likely to have an intraoperative complications compared to otolaryngologist, specifically in prolonged desaturation and mortality [9]. Preoperative optimizations to reduce the rate of intraoperative complications include minimizing ventilator setting, weaning vasopressors, and correction of coagulopathy. The most common early complication is bleeding which occurs in approximately 2.6% of cases. Percutaneous tracheotomy has a significantly higher rate of postoperative bleeding compared to an open method with a rate of 6.6% compared to 1.9% [9]. The use of security sutures to anchor the tracheostomy tube has been shown to decrease rates of early complications, specifically bleeding and accidental decannulation [9]. Placement of anchoring sutures is highly encouraged. Late complications are directly related to injury during placement of the tube, abnormal healing at site of injured tracheal mucosa, or prolonged need for inflated cuff [10]. The development of high-volume low-pressure tracheostomy tube cuffs has led to a ten-fold reduction in cuff site stenosis [10]. Insertion of appropriately sized tracheostomy tube and avoidance of overinflation of the cuff can assist in avoiding tracheal mucosal injury. Given that, it is the belief of this author that tracheostomies in critical ill patients such as those with end-stage liver failure should be performed in the operating room by an experienced otolaryngologist to minimize complications.

Appropriate decannulation is critical in avoiding long-term consequences of tracheostomy. Decannulation can be considered once the indication for tracheostomy tube placement has resolved. A consensus statement was published by the American Academy of Otolaryngologist in 2012, based on the Delphi survey outlining 77 statements to reduce variations in practice in management of tracheostomy [11]. A list of prerequisites for decannulation has been provided in Table 23.2. The decannulation process should be performed in the following manner: (1) Remove the tracheostomy tube; (2) Clean the site; (3) Cover the site with a dry gauze dressing; (4) Instruct the patient to apply pressure over the dressing with fingers when talking or coughing; (5) Change dressing daily and as needed if moist with secretions until the site has healed; and (6) Monitor for decannulation failure.