What is a Tracheostomy?
A tracheostomy is a surgical procedure that creates an opening (stoma) in the anterior wall of the trachea through the neck, allowing direct access to the airway for breathing, either temporarily or permanently. 1
Procedure Types
Tracheostomies can be performed using two main techniques:
- Open surgical technique: The traditional approach, particularly used in children where a vertical tracheotomy is created (rather than a cartilage window) to avoid stenotic segments 2
- Percutaneous technique: Predominantly used in adults, especially in critical care settings 1
Clinical Indications
Tracheostomies are performed for several critical reasons 1:
- Upper airway obstruction management (tumors, congenital malformations, bilateral vocal cord paralysis)
- Airway protection in patients unable to protect their own airway
- Facilitating weaning from mechanical ventilation in critically ill patients
- Long-term ventilation support for chronic respiratory failure
- Secretion management in patients unable to clear respiratory secretions effectively
In pediatric populations, additional indications include respiratory papillomatosis, caustic alkali ingestion, craniofacial syndromes, and subglottic stenosis 2.
Key Anatomical Differences from Normal Breathing
In patients with a tracheostomy, the upper airway (nose and mouth) is bypassed—air enters and exits directly through the neck stoma rather than through the nose or mouth. This creates what clinicians call "neck breathers" 1. This is fundamentally different from laryngectomy patients, where the upper airway cannot be connected to the trachea at all, though both groups breathe through their necks 1.
Temporary vs. Permanent
- Temporary tracheostomies: Used when the underlying condition is reversible (e.g., weaning from ventilation, temporary upper airway obstruction). In children, these often remain in place significantly longer than in adults, sometimes for months to years while awaiting growth or staged reconstructive surgery 2
- Permanent tracheostomies: Required when the underlying condition is irreversible (e.g., severe neurodegenerative disease, certain congenital abnormalities)
Complications to Recognize
Complications occur surprisingly frequently and directly impact morbidity and mortality 1, 2:
Immediate (during/immediately after procedure):
- Hemorrhage
- Loss of airway
- Pneumothorax/pneumomediastinum
Short-term (days to weeks):
- Tube blockage (mucus plugs)
- Tube displacement (complete or partial)—the most common serious complication
- Infection
Long-term (months to years):
- Tracheomalacia
- Tracheal stenosis
- Stomal problems (granulation tissue, infection)
Critical pitfall: Tube displacement and blockage are the most common life-threatening emergencies, particularly in the first week after placement before the stoma tract matures 1, 2. Children who are ventilator-dependent have worse outcomes following such incidents 2.
Tube Characteristics
- Adult tubes: Typically cuffed with inner tubes to maintain airway diameter
- Pediatric tubes: Generally uncuffed without inner tubes due to small tracheal diameter, to avoid further reducing the airway lumen 2
- Tubes may be fenestrated (with holes) or non-fenestrated, depending on the patient's needs for speech and ventilation
Epidemiology and Outcomes
In England alone, over 5,700 surgical and 5,000-8,000 percutaneous tracheostomies are performed annually in adults 1. Approximately 1,200 pediatric tracheostomies are performed yearly, with one-third in children under age one 2. Hospital mortality ranges from 9-20% in adults and 2-10% in children, though this is largely attributable to underlying comorbidities rather than the tracheostomy itself 2.