What Is Tracheostomy

Overview

A tracheostomy (sometimes called tracheotomy) is a medical procedure that involves creating an opening in the neck to access the windpipe or trachea.¹ Tracheostomy is one of the earliest surgical procedures ever recorded, dating back to pre-Christianity, with illustrations depicting it as early as 3600 B.C. in ancient Egypt.

In the past, a tracheostomy was the only available treatment for upper airway obstruction. This still remains an important indication for tracheostomy today; however, there are numerous others. The aim of the tracheostomy is usually to pass a tube through the opening created to provide oxygen or to clear any secretions clogging or blocking the pipe. This procedure is often conducted to assist breathing in people who have difficulty breathing due to various medical conditions and may not be suitable for or have responded to oxygen through other means. 

In this article, we will understand what a tracheostomy is, its purposes, and the situations in which it may be required, and try to gather insight into its significance in medical care.

The procedure for tracheostomy 

The tracheostomy procedure is performed in a sterile setting by a qualified medical professional, often a surgeon or an Otorhinolaryngologist (an ear, nose, and throat specialist, also called an ENT specialist). The procedure involves the following steps:

• Making an incision: An incision is made in the lower part of the neck, and a small opening is created in the windpipe.
• Creating the Stoma: The opening made in the trachea is called a stoma. A tube, known as a tracheostomy tube, is then inserted into this opening to maintain the airway patency and to deliver air or oxygen.
• Securing the Tube: The tracheostomy tube is secured in place with straps around the neck or with stitches.

Indications for tracheostomy

A tracheostomy may be required in several medical conditions.^2,3 The indications for tracheostomy can be divided into emergent tracheostomy, which is done in emergency scenarios such as trauma or blocked airways and elective tracheostomy, which is a pre-planned procedure.

Some indications include:

Respiratory Issues: 

Severe respiratory illnesses, such as Chronic Obstructive Pulmonary Disease (COPD) or Cystic Fibrosis, can cause breathing difficulties.

Long term conditions 

These are conditions such as Obstructive sleep apnea refractory to other treatments, Chronic aspiration, Subglottic stenosis and prior to head and neck cancer treatment.

Acute upper airway obstruction

These are especially situations where endotracheal intubation is not possible, including aspiration of a foreign body, angioedema, infections, and anaphylaxis.

Trauma or onjury: 

Trauma to the neck or upper chest region, such as those due to accidents or surgery, might lead to damage or blockage of the airway. This may then require a tracheostomy to maintain breathing.

Neuromuscular diseases: 

Conditions that affect the nerves and muscles involved in breathing, like spinal cord injuries or neuromuscular disorders, can also necessitate a tracheostomy.

Types of tracheostomy tubes

Following the creation of the opening or stoma, a tube is inserted and fixed in place. These tracheostomy tubes come in various sizes and designs, depending on the clinical needs of the patient:

• Standard Tubes: These tubes are made of medical-grade materials, such as plastic or silicone, and are available in different sizes to fit patients of various ages and sizes. They are used in longer-term patients who require ongoing suction to clear secretions. They are rarely used in urgent or acute situations.
• Cuffed Tubes: These tubes have a soft balloon around the distal end of the tube, which inflates to seal the airway. It sits inside the trachea, creating a seal to prevent of food or fluids from rebounding into the lungs and causing infections and complications. Cuffed tubes are necessary when positive pressure ventilation is required or in situations where the aim is to also prevent contents from the stomach or oral cavity from entering the windpipe and lungs. However, all cuffs are not an absolute barrier to secretions. 
• Fenestrated Tubes: These tubes have openings (fenestrations) in the tube wall, which allows some airflow through the vocal cords. Patients with these tubes may be able to speak and cough better as compared to those with a regular tracheostomy tube. However, the fenestrations increase the risk of the oral cavity or stomach contents entering the lungs. It is, therefore, crucial that patients who are at high risk of aspiration or those on positive pressure ventilation do not have a fenestrated tube. They can be used, however, if a non-fenestrated inner cannula is used to block off the fenestrations when required.

Care and management following a tracheostomy

Proper care, cleanliness and maintenance of the tracheostomy site are crucial to prevent infections and other complications:

• Regular Cleaning: Cleaning the area around the tracheostomy and changing the tube regularly, as advised by healthcare providers, is important to prevent infections.
• Suctioning: Clearing secretions from the airway using suction devices is necessary to prevent blockages, which can further make breathing difficult.
• Monitoring: It is important to attend regular check-ups and follow-ups with your healthcare professional to assess the condition of the tracheostomy site, check for optimum functioning and make sure there are no complications.

Factors influencing temporary tracheostomy tube choice 

• Respiratory function 
• Abnormal airway anatomy 
• Compromised airway, protection and weaning problems
• Speaking
• Obstructed or absent upper airway
• Clinical environment: The location where patients will be managed will also influence the choice of the tube. Simpler tubes without any additional suction ports and channels will be easier to understand and manage outside the hospital. If the patient is going to be discharged to a non-hospital environment, then it must be taken into consideration how easily the patient’s carers can maintain the device that is inserted. 

Complications of tracheostomy

Though tracheostomies are absolutely necessary and can even be life-saving at times, there are associated risks with the procedure. Thus, it is important to be vigilant and look out for the following:⁴

• Infection: Infection may be bacterial and present either at the site of the opening or within the airway. Pneumonia can be a complication of a tracheostomy if an aseptic technique is not used in suctioning the patient.
• Blocking of the airway: Obstruction of the tracheostomy tube is a common complication. The most frequent cause of obstruction was the plugging of the tracheostomy tube with a mucous plug or circumferential crusting. These plugs can also be aspirated into the lungs, blocking air entry to the alveoli (small airbags in the lungs) and leading to lung collapse or secondary infection. Thus, the tracheostomy tube is tied snugly, but it allows for the insertion of one finger between the tie and the neck.⁵
• Bleeding: Bleeding might be present at the site of the stoma. 
• Tube Dislodgement: The displacement or removal of the tracheostomy tube by accident or during movement can lead to breathing difficulties.
• Persistent opening: Failure of the stoma to close after removal of the tube may arise when prolonged tracheostomy has been done.
• Fistula: An abnormal connection between the trachea and food may be a rarer complication.

Summary

A Tracheostomy is the process by which an opening is made through the skin of the neck into the trachea (windpipe) to facilitate breathing in patients in whom other interventions are not successful. It is a vital intervention that can greatly improve the quality of life and be life-saving with certain medical conditions. The procedure provides a secure airway, which supports breathing and in some forms of tracheostomies, can even facilitate speech. However, the decision to perform a tracheostomy involves careful consideration and should be guided by experienced medical professionals. It is necessary to understand the possible complications of the procedure and to be vigilant of any danger signs.