An Overview of Tracheostomy

A tracheostomy, also called a tracheotomy, is a surgical procedure that involves making an incision in the skin of the neck and through the trachea (windpipe) in order to facilitate breathing. It is often, but not always, done in an emergency. The procedure may be temporary or permanent depending on individual circumstances.

Purpose

A tracheostomy is always done to help someone breathe, but there are many reasons why this might be necessary including emergencies such as:

• Tracheostomy may be necessary during choking if the object blocking the airway is located in the upper airway and other methods such as the Heimlich maneuver have been unsuccessful in removing it.
• Neck trauma such as injuries to the thyroid or cricoid cartilages, the hyoid bone, or severe facial fractures.
• Swelling of the upper airways due to injury, infection, burns, or a serious allergic reaction (anaphylaxis).
• Congenital abnormalities of the upper airway such as a vascular web or laryngeal hypoplasia.
• Vocal cord paralysis
• To facilitate long periods of time on a mechanical ventilator due to respiratory failure.
• Subcutaneous emphysema
• Spinal cord injuries

Other reasons you might need a tracheostomy include:

• Severe sleep apnea that has not responded to other treatments such as CPAP or surgeries to remove enlarged tonsils or other obstructions.
• Neuromuscular disorders that can affect your ability to breathe or control your own secretions such as spinal muscular atrophy.
• Chronic pulmonary diseases
• Chronic conditions of the muscles or nerves in the throat that have or may result in aspiration (inhaling saliva or other substances into the lungs).
• Tumors that threaten to obstruct the airway
• Treacher-Collins syndrome or Pierre Robin syndrome
• When long-term ventilation is anticipated such as when an individual is in a coma.
• To aid in the recovery of extensive head or neck surgery

Procedure

In the event of an emergency, in order to restore breathing as quickly as possible a tracheostomy may be done without any anesthesia. In other cases the procedure is done under general or local anesthesia to make the patient as comfortable as possible. Different situations may warrant slightly different techniques.

A tracheostomy is ideally performed in an operating room under general anesthesia but depending on why it is performed and the situation it may be done in a hospital room or even at the scene of an accident. It is becoming more common for tracheostomies to be done in an intensive care unit (ICU) rather than an operating room. The procedure itself can be performed fairly quickly (in 20 to 45 minutes).

Usually in an emergency situation, a vertical incision is used to avoid the blood vessels, which also travel vertically. The person performing the tracheostomy determines the best place to put the incision by locating important landmarks in the neck including the innominate artery, cricoid cartilage, and thyroid notch.

If possible the skin should be well cleaned with surgical scrub prior to making the incision to help prevent infection. This may not be possible in the event of an emergency.

After this initial incision is made in the neck and important internal anatomical structures are also located a second cut or a puncture is made in the trachea (windpipe) through which a tracheostomy tube is inserted. If a puncture technique is used this is called a percutaneous tracheostomy rather than an open tracheostomy. The tube is secured using sutures and keeps the incision (stoma) open as long as it is in place. When the tube is removed the opening heals in about a week.

Potential Complications

As with any surgical procedure potential complications of a tracheostomy may include the risk of bleeding, infection, or adverse reaction to anesthesia or other medications used during the procedure.

Additionally, life threatening complications can occur during a tracheostomy including the possibility that breathing will be interrupted long enough for hypoxia (lack of oxygen) to occur and cause permanent complications (such as brain injury).

Anatomical structures such as the laryngeal nerves, or esophagus can also potentially be injured during a tracheostomy. Additional complications that may occur include:

• Pneumothorax
• Pneumomediastinum
• Pulmonary edema
• Subcutaneous emphysema (air trapped underneath the skin around the tracheostomy)
• Blockage of the tracheostomy tube from blood clots or mucus

Tracheitis (inflammation and irritation of the trachea) is a common complication that occurs in most individuals who undergo tracheostomy. This is managed using humidified air and irrigation. Discomfort can also be minimized by preventing movement of the tube.

Potential complications from having a tracheostomy tube long term can include:

• Infection
• Tube displacement
• Scarring of the trachea
• Abnormal thinning of the trachea (tracheomalacia)
• Fistula

Complications may be more likely to happen in people undergoing tracheostomy who:

• Are infants
• Are smokers or heavy drinkers
• Have other serious health problems such as compromised immunity, diabetes or respiratory infections
• Have taken steroid medications such as cortisone for a long time

Tracheostomy Recovery

The tracheostomy tube is held in place with velcro or ties. You may have a sore throat or pain at the incision site after a tracheostomy which may be controlled with pain medications if necessary. Pain is more likely to occur if there is movement of the tube so the tube should be secured and if you are on a ventilator care should be taken that all tubes are also stabilized.

As previously mentioned tracheitis is common during the recovery period. Tracheitis can result in increased secretions which must be routinely suctioned to avoid mucus clogs in the tracheostomy tube (sometimes as often as every 15 minutes initially). Adequate fluid intake and humidified oxygen are helpful in thinning secretions and making them easier to suction. Medications such as guaifenesin may also be used to control secretions.

Initially a cuffed tracheostomy tube will be used right after the tracheostomy is performed. Cuffed trach tubes make it impossible for air to pass through the vocal cords so you can't talk until the cuff is deflated or the tube is changed.

Speaking may be encouraged after you no longer need mechanical ventilation. Speaking after a tracheostomy requires plugging the tube with a finger or the use of a special valve cap called a Passy-Muir valve. It may take practice to learn to speak with a tracheostomy.

Swallowing can be more difficult with a tracheal tube in place but once your medical team feels you are up to it you can begin eating and drinking.

Tracheostomy Maintenance

Most of the time a tracheostomy is only needed for a very short period of time but sometimes you may be discharged from the hospital with a tracheostomy. If this is the case you will be instructed on how to care for your tracheostomy at home.

Depending on circumstances this care may be performed by family members, home health staff or nurses. The tracheostomy tube itself may need to be changed periodically. This is usually done by a nurse or doctor and emergency breathing equipment should be on hand in case anything happens while the tube is being changed.

Other maintenance of a tracheostomy usually includes suctioning if and when necessary. You should try to drink a lot of fluids and may need to use a humidifier of some kind to help manage your secretions.

In addition to suctioning you may need to perform site care, which usually involves cleaning the area around the trach tube with normal saline solution. The dressings around the trach tube may also need to be regularly changed and immediately if they become wet. Sometimes special creams or foam dressings are first applied to help the skin in this area.

Special care is necessary when providing routine maintenance of the tracheostomy such as dressing changes to make sure that the tube does not accidentally become dislodged.

Removal (Decannulation)

With the exception of certain chronic or degenerative conditions most tracheostomies are only temporary. The tube should be removed as soon as possible for the best outcomes. Some indications that it is time to remove the tracheostomy tube include:

• You are awake and alert
• Mechanical ventilation no longer required
• You are able to manage your own secretions without frequent suctioning
• You have a restoration of your cough reflex

Once these requirements are met there is usually a trial period of 24-48 hours during which time your tracheostomy is plugged and your oxygen is monitored to see how you do without the use of the tracheostomy. Your ability to control your own secretions is also monitored during this time. If you are able to keep your oxygen levels up and don't require too much suctioning during this trial period you're probably ready to have your tracheostomy tube removed.

The actual removal of the tube is called decannulation. It is not uncommon to feel a bit short of breath briefly right after the tube is removed but this should subside. The stoma (opening through which the tube resided) is generally covered with gauze or tape (or both). You will probably still have to cover the stoma with a finger to speak for a while. The stoma typically heals in five to seven days after the tube is removed.

In some cases, especially when the tracheostomy tube was in place for an extended period of time the stoma may not heal on its own. In this case the stoma can be closed surgically.