What is a Tracheostomy?
A tracheostomy is a surgical procedure that creates an opening through the front of your neck into your windpipe (trachea), where a tube is inserted to help you breathe when the normal airway is blocked or when you need prolonged breathing machine support. 1, 2
Why You Might Need a Tracheostomy
For patients with COPD or recurrent pneumonia requiring prolonged mechanical ventilation (breathing machine support expected beyond 10-14 days), tracheostomy should be strongly considered to reduce airway damage from the breathing tube through your mouth and to facilitate weaning from the ventilator. 3, 4
Main Reasons for Tracheostomy:
Prolonged mechanical ventilation: When you need a breathing machine for more than 10-14 days, a tracheostomy prevents damage to your voice box from the tube going through your mouth 4, 5
Upper airway obstruction: When swelling, tumors, or other problems block your normal breathing passage 1, 6
Secretion management: When you cannot effectively cough up mucus and secretions on your own, particularly important in COPD patients 6, 2
Planned major surgery: For certain head and neck operations where airway swelling is expected 1
How the Procedure is Done
Either open surgical tracheostomy (OST) or percutaneous dilatational tracheostomy (PDT) can be performed based on your specific situation, with both techniques being equally acceptable. 7
Two Main Techniques:
Percutaneous dilatational tracheostomy (PDT): Done at your bedside in the ICU using a needle and dilators to create the opening, typically with camera guidance 6, 4
Open surgical tracheostomy (OST): A traditional surgical procedure, preferably performed at your bedside in the ICU rather than the operating room 7
The procedure should be performed by the most experienced team with the fewest number of providers to minimize complications. 7
What to Expect After the Procedure
Immediate Changes:
Breathing: You will breathe through the tube in your neck instead of your nose and mouth 2
Speaking: You will initially be unable to speak normally, though speaking valves may be used later to help restore your voice 3
Secretion management: Regular suctioning will be needed to remove mucus from your airway 8
Important Care Requirements:
Proper humidification is the single most important measure to prevent complications, as the tracheostomy bypasses your nose and mouth which normally warm and moisten the air you breathe. 8
Humidification: Inspired air must be warmed to 32-34°C with humidity of 36-40 mg/L to prevent secretions from becoming thick and blocking the tube 8
Regular suctioning: Your secretions must be removed regularly to prevent tube blockage 9, 8
Skin care: The area around the opening must be kept clean and dry to prevent infection 8
Potential Risks and Complications
Immediate Risks:
Bleeding: Can occur during or immediately after the procedure 3, 2
Loss of airway: Rare but serious complication requiring immediate intervention 3
Infection risk: Both to you and to healthcare workers, particularly if you have infectious respiratory disease 7, 3
Ongoing Risks:
Tube obstruction from mucus plugs is one of the most common and life-threatening emergencies in tracheostomy patients, presenting as high-pitched wheezing and requiring immediate suctioning or emergency tube change. 9
Mucus plugging: Thick secretions can block the tube, causing breathing difficulty 9
Swallowing problems: Increased risk of food or liquid going into your lungs 3
Tube displacement: The tube can accidentally come out, especially in the first week 2
Tracheal damage: Long-term complications can include scarring or narrowing of the windpipe 2
Special Considerations for COPD and Pneumonia Patients
Patients with COPD or history of pneumonia are at particularly high risk for thick, tenacious secretions that can obstruct the tracheostomy tube, requiring vigilant monitoring and aggressive humidification protocols. 9
Increased secretions: Your underlying lung disease means you produce more mucus that must be managed 8
Reduced cough: If you are weak or sedated, you cannot cough effectively to clear secretions 9
Infection risk: Your compromised lungs make you more susceptible to pneumonia through the tracheostomy 3
Communication and Quality of Life Impact
The impact on your ability to speak and communicate must be carefully discussed, including the potential use of speaking valves once your condition stabilizes. 3
Speech limitations: You will need alternative communication methods initially (writing, gestures) 3
Cosmetic concerns: There will be a visible opening in your neck that many patients find distressing 3
Lifestyle changes: You will need specialized care and cannot swim or shower normally 3
Home Care Requirements
Before discharge home with a tracheostomy, you must have two trained adult caregivers who can manage the tube, perform suctioning, and handle emergencies. 3
Essential Skills Your Caregivers Must Learn:
Emergency tube changes: How to replace the tube if it comes out 9
Suctioning technique: Proper removal of secretions 8
Recognition of obstruction: Identifying when the tube is blocked 9
Humidification management: Maintaining proper moisture in the airway 8
Decision-Making and Alternatives
A multidisciplinary team including your critical care doctors, palliative care specialists, infectious disease experts, and the procedural team should discuss your goals of care, the risks and benefits, and alternatives before proceeding. 7
Alternatives to Consider:
Continued oral/nasal intubation: Keeping the breathing tube through your mouth, though this causes more damage if prolonged 5
Noninvasive ventilation: Using a mask instead of a tube, though this may not be feasible in your situation 3
Comfort measures only: If prolonged ventilation does not align with your goals of care 3
Your autonomy and wishes must be respected after you receive appropriate education about what a tracheostomy entails. 3
Critical Warning Signs
If you experience high-pitched wheezing sounds from your tracheostomy, this indicates tube obstruction and requires immediate emergency intervention—suctioning first, and if that fails, emergency tube change without delay. 9