Tracheostomy

Original Editor - Natalie Patterson Top Contributors - Natalie Patterson, Lucinda hampton, Ines Musabyemariya, Uchechukwu Chukwuemeka, Pacifique Dusabeyezu and Kim Jackson

Introduction

A tracheostomy is a surgical opening in the anterior wall of the trachea. Traditionally a tracheostomy is performed as an open surgical procedure, however safe and reliable percutaneous tracheostomy techniques have been developed, allowing for the bedside placement of a tracheostomy in many patients.

This 6-minute video explains what a tracheotomy is.

Percutaneous Tracheostomy

Percutaneous Tracheostomy also known as Percutaneous dilatational tracheostomy (PDT) is a surgical procedure invented by Ciaglia in 1985 and it involves blunt dissection of anterior tracheal tissues followed by dilatation of the trachea over the guidewire and insertion of tracheal cannula using the Seldinger technique.

PDT is a bedside surgical procedure that creates an opening in the anterior tracheal wall to maintain an airway when obstructed. It's typically performed on patients expected to need mechanical ventilation for longer than seven days. Still, the final decision is made on a case-by-case basis

Percutaneous dilatational tracheostomy (PDT) has now become the standard of care in the ICU and has replaced ST in this subset of patients to a large extent. It however remains imperative to be aware of conditions where ST may be preferable, in the intensive care unit (ICU) PDT is typically indicated for the following reasons:

• To facilitate weaning in patients who have difficulty weaning off the ventilator.
• To assist with clearing the trachea and bronchi.
• To protect the airways in patients who are at risk of aspiration.
• In cases of anticipated prolonged need for ventilator support.
• To reduce the need for sedation.

It is really important to note that PDT is not generally performed as an emergency procedure unless it is carried out by an experienced operator.

Surgical Tracheostomy

Surgical Tracheostomy (ST) involves dissection and incision of the trachea under direct vision.

Tracheostomy with tube

Surgical tracheotomy can be performed in an operating room or a hospital room. The person is positioned on their back, and a rolled-up towel (or equivalent) is placed under the shoulders to help stretch the person's neck. Local anaesthetic is injected into the target area, and a skin incision (cut) is made. The surgeon will then open either the 3rd or 4th tracheal ring (this is called a ‘tracheostomy’) or the cricothyroid membrane - the thinnest part of the airway below the larynx (this is called a ‘cricothyroidotomy’). The airway tube is inserted into the trachea and the person is connected to the oxygen supply. The entire procedure is done as quickly as possible.

Indications for a Tracheostomy

Airway obstruction

• To secure and clear the airway in upper respiratory tract obstruction
• An obstruction, often caused by cancer, swelling of the airway, infection, inflammation or trauma
• Where an airway is predicted to get worse and possibly become obstructed E.g. after major head and neck surgery

Providing an artificial airway for ventilation

• A tracheostomy is usually well tolerated and typically does not require sedation once it has been inserted.
• It is the best way of invasively ventilating a patient in the medium to long term, it provides a secure airway without directly interfering with the larynx
• It can facilitate weaning from ventilation.
• It can enable long-term mechanical ventilation of patients, either in an acute setting or long-term.

Protecting the airway

• Some patients are at high risk of aspirating secretions or gastric contents into the airway. E.g. neuromuscular disorders, head injuries, unconsciousness, stroke or following prolonged disuse such as after trans-laryngeal intubation (Endotracheal Tube)
• A tracheostomy tube with the cuff inflated reduces the risk and offers some protection against aspiration
• Sub-glottic suction systems can help to reduce secretions that enter the airway

Respiratory secretion management

• To facilitate the removal of bronchial secretions where there is poor cough effort with sputum retention
• Tracheostomy allows manual insufflation-exsufflation (cough assist) to be applied directly to the lungs
• Suction directly into the trachea to help clear secretions.

Other Reasons for a Tracheostomy

• Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm
• Aspiration related to muscle or sensory problems in the throat
• Fracture of cervical vertebrae with spinal cord injury
• Long-term unconsciousness or coma
• Disorders of respiratory control such as congenital central hypoventilation or central apnea
• Facial surgery and facial burns
• Anaphylaxis (severe allergic reaction)

Physiological Changes

• The upper airway anatomical dead space can be reduced by up to 50%. - This space takes no part in gas exchange and adds to the work of breathing. Reducing this can help patients wean off a ventilator more easily.
• The natural warming, humidification and filtering of air that usually takes place in the upper airway is lost
• The patient's ability to speak is removed/reduced as the cuff impairs the swallowing mechanisms of the larynx
• The ability to swallow is adversely affected
• Sense of taste and smell can be lost which can harm appetite.
• Altered body image

Complications

Perioperative period

• Haemorrhage
• Misplacement of a tube - within tissues around the trachea or to the main bronchus
• Pneumothorax
• Tube occlusion
• Surgical emphysema
• Loss of the upper airway

Postoperative period < 7 days

• Tube blockage with secretions or blood
• Partial or complete tube displacement
• Infection of the stoma site
• Infection of the bronchial tree (pneumonia)
• Ulceration, and/or necrosis of trachea or mucosal ulceration by tube migration
• Risk of occlusion of the tracheostomy tube in obese or fatigued patients who have difficulty extending their neck
• Tracheo-oesophageal fistula formation
• Haemorrhage

Late postoperative period >7 days

• Granulomata (a mass of granulation tissue) of the trachea may cause respiratory difficulty when the tracheostomy tube is removed
• Tracheal dilation, stenosis or tracheomalacia (trachea partly collapses especially during increased airflow)
• Scar formation-requiring revision
• Haemorrhage

Types of Tubes

Cuffed with fenestrated tubes

Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak

Cuffed with unfenestrated tubes

Used to obtain a closed circuit for ventilation

Uncuffed with fenestrated tubes

Used for patients who have difficulty using a speaking valve

Uncuffed with unfenestrated tubes

Used for patients with tracheal problems

Used for patients who are ready for decannulation

The patient may be able to eat and may be able to talk without a speaking valve.

Resources

UK National Tracheostomy Safety Project http://www.tracheostomy.org.uk/

Watch a Tracheostomy https://www.hopkinsmedicine.org/tracheostomy/video/watching.html