Tracheostomy

Introduction

A tracheostomy is a surgical opening in the anterior wall of the trachea. There are two types of tracheostomy; a percutaneous tracheostomy and a surgical tracheostomy.

Percutaneous Tracheostomy

A percutaneous tracheostomy has been formed by stretching (dilating) the tissues which will spring back into their original places if the tube is removed. A percutaneous tracheostomy is generally preferred to surgical tracheostomy in intensive care patients as it can be performed on the ICU, thus eliminating the logistical problems that may occur when transferring a ventilated patient to the operating theatre. There are six different techniques that are commonly performed can be distinguished:multiple dilator tracheostomy, rotational dilation tracheostomy, and translaryngeal tracheostomy.

Balloon dilatational technique

This involves the same initial stages as the Single tapered dilatational technique, but instead of a curved dilator a pressurised balloon is used to dilate the trachea to allow passage of the tracheostomy tube.

Guide wire forceps (Griggs technique)

Following the insertion of a guide wire, dilator forceps are advanced alongside the wire and into the trachea. These forceps are then opened splitting the tracheal membrane to the desired diameter to allow insertion of the tracheostomy tube.

The Ciaglia serial dilatational technique

A cannula or needle is inserted into the trachea. The guide wire is then passed in a caudal direction before a primary dilator is passed over the wire to begin dilatation of the tract. A white plastic sheath is positioned over the wire to act as a guide for the dilators. The dilator must be inserted over the guiding catheter up to a safety ridge, this is necessary to prevent damage to the curved dilator tip and kinking of the guiding catheter. Dilators of increasing size are used and once the tract is sufficiently dilated, a tracheostomy tube loaded onto the appropriately sized dilator is passed over the guide wire and plastic sheath into the patient's trachea.

Single tapered dilatational technique

This is a modification of the Ciaglia technique and uses a single tapered dilator. The one-step dilatation is faster and is the commonest method of percutaneous tracheostomy used in the UK.

Surgical Tracheostomy

A surgical tracheostomy stoma is usually cut and stitched open and are more likely to have an established stoma within a day or 2 (or even straight away) after a tracheostomy.

Horizontal slit 

A horizontal or T-shaped tracheal opening through the membrane between the second and third or third and fourth tracheal rings. A silk stay suture can be placed through the tracheal wall as this pulls the trachea anteriorly and widens the opening.

Window

Removal of small anterior portions of the tracheal rings can create a more permanent stoma.

Vertical slit

A 'U' or 'H' shaped tracheal opening can be made and the tracheal flaps can be tacked to skin edges with absorbable sutures to create a semi-permanent stoma (Fig 3). Sutures can be placed in each tracheal flap and taped to the chest and neck skin, facilitating replacement of a displaced tube in postoperative care. Pulling on these sutures widens the tracheal opening. Most modern adult surgical tracheostomies will be performed in this way

Björk flap

A different type of surgical tracheostomy is the Björk flap where a ‘ramp’ of trachea is sutured to the skin which allows easier replacement of tracheostomy tubes (Fig 4). There may be a suture to the skin here too, but this is to hold the ‘ramp’ in place, rather than to be used to elevate the trachea for a tracheostomy tube change. If Björk flap sutures are pulled, they may tear the ‘ramp’ and occlude the stoma.

Björk flap tracheostomies are not commonly performed, but if they are done in your hospital, you need to know what the bits of suture coming out of the stoma will do when pulled!

Indications for a Tracheostomy

Airway obstruction

• To secure and clear the airway in upper respiratory tract obstruction
• An obstruction, often caused by a cancer, swelling of the airway, infection, inflammation or trauma
• Where an airway is predicted to get worse and possibly become actually 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 have a negative impact on appetite.
• Altered body image

Complications

Perioperative period

• Haemorrhage
• Misplacement of tube - within tissues around trachea or to 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

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