Understanding Tracheostomy
A tracheostomy is a surgical opening created in the front of the neck into the trachea (windpipe) to provide an alternative airway for breathing when the normal upper airway passage is compromised or needs to be bypassed. 1
What is a Tracheostomy?
A tracheostomy is a surgical procedure that creates an opening (stoma) between the trachea (windpipe) and the skin of the neck. This opening allows air to flow directly into the lungs, bypassing the nose, mouth, and upper airway structures.
Types of Tracheostomy
Temporary vs. Permanent:
- Temporary tracheostomies are used for short-term airway management
- Permanent tracheostomies may be required for patients with irreversible conditions 1
Surgical Techniques:
- Open Surgical Tracheostomy: Traditional method performed by surgeons
- Percutaneous Dilatational Tracheostomy: Less invasive technique often performed at bedside in ICUs 1
Why Are Tracheostomies Performed?
Tracheostomies are performed for several important reasons:
- Management of upper airway obstruction
- Airway protection in patients who cannot protect their own airway
- Facilitating weaning from mechanical ventilation
- Enabling long-term ventilation support
- Assisting with removal of respiratory secretions 1, 2
In children, common indications include subglottic stenosis, bilateral vocal cord paralysis, tumors, congenital airway malformations, and respiratory papillomatosis 1.
The Tracheostomy Procedure
The procedure involves:
- Creating an incision in the front of the neck
- Carefully accessing the trachea between cartilage rings
- Creating an opening (stoma) in the trachea
- Inserting a tracheostomy tube to keep the airway open 1
In adults, a cartilage window may be created, while in children a vertical incision is preferred to avoid creating a stenotic segment 1.
Tracheostomy Tubes
Tracheostomy tubes come in different types:
- Cuffed tubes: Have an inflatable balloon that seals the airway (often used with ventilators)
- Uncuffed tubes: No balloon, allow some air to flow around the tube
- Fenestrated tubes: Have an opening that can allow speaking when the outer opening is covered
- Single vs. double cannula tubes: Double cannula tubes have an inner tube that can be removed for cleaning 1
Children typically use uncuffed tubes without inner cannulas to maximize the internal diameter 1.
Complications of Tracheostomy
Complications can occur at different stages:
Immediate Complications
- Bleeding
- Loss of airway
- Pneumothorax
Short-term Complications
- Tube blockage by secretions
- Tube displacement
- Infection
Long-term Complications
- Tracheal stenosis
- Tracheomalacia (weakening of tracheal walls)
- Granulation tissue formation
- Problems with the stoma site 1, 3
The most dangerous emergency complications are tube dislodgement, obstruction, and hemorrhage 3.
Living with a Tracheostomy
Daily care of a tracheostomy includes:
- Regular cleaning of the tube and surrounding skin
- Suctioning to remove secretions
- Humidification to prevent drying of the airway
- Changing tracheostomy ties securely
- Monitoring for signs of infection or complications 1
Patients and caregivers must always carry emergency supplies including:
- Spare tracheostomy tubes (current size and one size smaller)
- Suction equipment
- Scissors to cut ties in emergency
- Manual resuscitation bag 1
Emergency Management
For tracheostomy emergencies, remember this critical point:
Tube obstruction is the most common cause of severe respiratory distress in a person with a tracheostomy and must be treated as an emergency—when in doubt, change the tracheostomy tube! 1
Quality of Life Considerations
A tracheostomy impacts several aspects of daily life:
- Communication: Speaking may require special techniques or devices
- Eating and swallowing: May be affected, especially initially
- Appearance: The visible stoma can affect body image
- Activities: Swimming and water activities require special precautions
- Respiratory health: Increased vulnerability to respiratory infections 1, 4
Despite these challenges, tracheostomies often improve overall quality of life by providing a secure airway, enabling better respiratory support, and in many cases, allowing patients to leave intensive care settings sooner 2.
Conclusion
Tracheostomies play a vital role in airway management for many patients with various medical conditions. While they come with challenges and potential complications, they can significantly improve breathing, comfort, and survival for those who need them.