Tracheostomy Common Questions

What is a tracheostomy?

 

  A tracheostomy is a medical intervention in which a tube is introduced inside the body to provide a breathing airway. This process is achieved through an incision made on the air passage from the throat to the lungs. In some cases, a tracheostomy is performed when there is an obstruction in the respiratory tract. This provides room momentarily for regaining the ability to breathe.  Sometimes, an individual dealing with some type of lasting injury in the voice box might need a tracheostomy for a long time. Therefore, according to the type of medical condition a tracheostomy can be either short-term or long-term.

  “A tracheostomy is a surgery that creates an opening through the front of your neck into the trachea (windpipe). A tracheostomy tube is usually put through this hole into the windpipe. However, the word tracheostomy is commonly used to describe both the surgery and/or the tube. Tracheostomy tubes allow people who cannot breathe on their own to be connected to a ventilator (breathing machine) or receive additional oxygen. It also allows air to bypass an injury or blockage in the upper part of the windpipe to reach the lungs.” (1)

 

Why is a tracheostomy done?

 

  This procedure is put into action because of an inability to get air into the lungs. There are various circumstances that lead to it, which can be further classified as non-emergency and emergency situations.

  • Non-emergency situations are varied. To illustrate, tracheostomies are performed before a surgery involving the respiratory system so that the individual might be able to breathe and therefore survive.
  • Emergency situations arise when there is an obstruction in the respiratory tract, therefore preventing the individual to breathe properly. This situation usually involves the use of a respirator and requires getting a tube into the airways. This tube works along an oxygen container to help the patient breathe.

  “Placement of a tracheostomy is usually an elective procedure and there are generally four reasons to place a tracheostomy. These are: to relieve upper airway obstruction (due to tumor, surgery, trauma or infection), to prevent laryngeal and upper airway injury due to prolonged tracheal intubation, to provide access to and protect the lower airway from aspiration, and to provide a stable airway for patients requiring prolonged mechanical ventilation or oxygenation support. Although there are no randomized studies to support the first indication, this was the reason one of the first emergency tracheostomies which was performed on the battle field in antiquity and remains a common indication today.” (2)

  “Tracheostomies are commonly provided to intensive care unit (ICU) patients to facilitate mechanical ventilation or to provide airway protection. There is general agreement that tracheostomies should be performed in patients who are anticipated to require prolonged mechanical ventilation, yet appropriate indications, timing, and optimal patient selection remain uncertain. Recent randomized controlled trials have established that a strategy of routinely performing early tracheostomies confers no survival benefit yet likely results in excess procedures. More emphasis is now placed on other potential benefits of a tracheostomy, including improving comfort during prolonged mechanical ventilation, reducing sedation requirements, and facilitating weaning—yet these advantages have not been firmly established. The impact of this evolving evidence base on actual practice patterns is uncertain.”(3)

 

How to take care after the procedure?

 

  “Tracheostomy is an essential and common part of modern airway management. It is commonly seen in a variety of specialties, including surgical, medical and critical care settings. A significant number of patients have permanent tracheostomies that require long-term care and management. Improper tracheostomy care can result in adverse outcomes.” (4)

  There are some parameters to take into consideration after the procedure has taken place. Usually, if everything goes right as planned during the surgery, the patient must rest in the healthcare facility for a period lasting no more than 5 days. One has to consider that it might take a number of days to get used to breathing with the trach tube; as a result, it might be difficult to speak. Thorax radiographies are common and are done to ensure the trach tube is placed in the right position. In addition, there are instances in which medication is recommended after this surgical intervention to avoid the possible development of damaging organisms.

  It is important, not only to take care of yourself, but also the trach tube.  Your physician should instruct you and your caregiver about the measures necessary to maintain the tube in its most hygienic condition.

 

What are the benefits of Tracheostomy?

 

  “In the past, it was recommended that if intubation is projected to be longer than 3 weeks, tracheostomy should be considered at that time. Current recommendations are that the decision of when to perform a tracheostomy should be individualized by the patient and the disease process. The decision of when to perform a tracheostomy should be made by balancing the patient’s wishes, the expected recovery course, the risks of continued translaryngeal intubation, and risks of the tracheostomy. Because tracheostomy offers several important patient benefits over continued translaryngeal intubation, including improved comfort, better oral hygiene, improved communication, better opportunity for oral feeding, and easier, safer nursing care, it should not be inordinately delayed. Additional benefits may accrue due to the need for less sedation and analgesia, and the lower work of breathing through the tracheostomy tube which may facilitate the weaning process.” (5)

  “To reduce the consequences of prolonged MV (mechanic ventilation), evidence from numerous studies has indicated that early tracheostomy is recommended for prolonged MV patients in stable conditions. The benefits include improving comfort, safety, and oral hygiene, as well as reducing the use of sedatives and hypnotics. The procedure also enables early ventilator weaning and reduces the risks of pneumonia and mortality. Consequently, health care costs are reduced, and patients’ quality of life is also increased. On the contrary, some studies found patients without tracheostomy had shorter MV durations, suggesting that the evidence is inconsistent across studies.” (6)

  “Putative benefits and disadvantages of tracheostomy

Advantages:

  • Decrease in ventilatory dead space
  • Decreased airway resistance
  • Ease of suctioning
  • Reduced orolabial and laryngeal trauma
  • Overall patient comfort
  • Reduced requirement for sedation
  • Increased patient mobility
  • Shorter duration of mechanical ventilation (owing, in part, to reduced sedation requirements)
  • Ability to transfer spontaneously breathing patients to non–intensive care unit setting
  • Ease of tube replacement (once tract matured)
  • Increased ability for the patient to communicate (verbal and nonverbal)
  • Variable capacity for oral intake of nutrition and medication

 

Disadvantages:

  • Complications at cuff site
  • Requires specialized skill set, equipment, environment and personnel for insertion
  • Stoma site bleeding
  • Stoma site infection
  • Possible contribution to subsequent tracheal stenosis
  • Tracheoinomminate artery fistula, catastrophic bleeding
  • Subsequent scar at stoma site
  • Complications leading to death” (7)

 

What problems can arise after a tracheostomy?

 

  Since this procedure involves surgical intervention, a person might experience some issues after it’s done. A tracheostomy can lead to:

  • Harm to the gullet
  • Harm to the throat
  • Pneumothorax
  • Excessive blood loss

 

  Some issues involving the trach tube may also arise, including:

  • The obstruction of the tracheostomy tube by body fluids
  • The unsuccessful closure of the incision made after the tube is taken off
  • The displacement of the track tube
(8)

  “A number of mechanisms can cause late complications after tracheostomy. Complications can be directly related to placement of the tube, leaving the tube in place for a prolonged period of time, or abnormal healing at the site of injured tracheal mucosa. As with a translaryngeal endotracheal tube, complications may be related to the inflated cuff of the tracheostomy tube or the tip of the tube, especially when it impinges on the posterior tracheal wall. In contrast, the tracheostomy stoma leads to a unique set of airway complications. Once airway injury occurs, other factors may serve as exacerbating factors. As an example, chemical injury from either gastroesophageal reflux or laryngopharyngeal reflux can aggravate the extent of damage of an already injured airway. Pooling of inflammatory secretions above the tracheostomy cuff can further injure the airway.” (9)

  It is important to highlight that not all people experience these issues after a tracheostomy.  However, there are some people who are more likely to suffer from them, such as:

  • Infants
  • People who smoke
  • People  in the later stages of life

 

Is tracheostomy a common procedure?

 

  “Although many factors may have contributed to rising use of tracheostomy from 1993 to 2008, it is less clear why rates of tracheostomy subsequently have begun to decline. We speculate that more recent randomized trials and metaanalyses that have showed no difference in mortality or ventilator-associated pneumonia with early tracheostomy may have decreased enthusiasm for early tracheostomy, resulting in fewer tracheostomy procedures. Alternatively, it is possible that with increasing use of advance directives and better data on long-term outcomes of chronic critical illness fewer families are opting to pursue prolonged MV and are instead choosing to pursue less invasive, more comfort-based care. Finally, it is possible that emerging evidence and guidelines encouraging reduced use of sedatives and improved processes for ventilator weaning have resulted in fewer cases of prolonged MV and less need for tracheostomy in later study years.” (10)

(11)

 

What is the material used to make a tracheostomy?

 

  “Tracheostomy tubes can be plastic (polyvinyl chloride or silicone) or metal (silver or stainless steel), uncuffed or cuffed, unfenestrated or fenestrated. They include a subglottic aspiration port or speaking valve. Specifications include the outer-diameter, inner-diameter and length (angled or curved, standard or extra-length, fixed-length v. adjustable flange). Extra horizontal length is available for large necks, whereas extra vertical length may help with tracheal anomalies. All tracheostomy tubes include an obturator to assist with insertion.

  Tubes can have a single or dual cannula. Dual-cannula tubes possess an inner cannula and will not connect to a ventilator without it. The supposed advantage is quicker and easier cleaning of the inner tube to prevent gradual obstruction with secretions (although evidence that this decreases pneumonia is lacking). Disadvantages include a smaller internal diameter, which may increase the work of breathing and paradoxically trap secretions.” (12)

  “In conclusion, tracheostomy can offer several advantages in the management of critically ill patients who need mechanical ventilation and/or airway control. The optimal timing of tracheostomy remains controversial, but it appears that early tracheostomy in selected patients, such as those with severe trauma, burns and neurological injuries, may be effective in reducing the duration of mechanical ventilation, ICU stay and costs. Percutaneous tracheostomy techniques are becoming the procedures of choice in the majority of cases because they are safe, easy and quick, and complications are minor. However, percutaneous tracheostomies should always be performed by experienced physicians so that unnecessary additional complications may be avoided. It is not clear whether any one percutaneous technique is superior to any other, but experience of the operator and the anatomical and physiopathological characteristics of the patient should always be considered. The operator should have experience of at least one intrusive and one extrusive percutaneous technique. In general, the ‘optimal’ tracheostomy does not exist; we must use the right technique in the right patient and at the right time.” (13)

 

References:

(1) Tracheostomy in Adults. Mehta, A.B & Syeda, S.N. ATS Patient Education Series. 2016. (p.1) https://www.atsjournals.org/doi/pdf/10.1164/rccm.1942P3

(2, 5) Tracheostomy. Cioffi, W.G., Conolly, M.D, Adams, C.A., Crawford, M.C, Richman, A., Shoff, W.H. & Cogbill, T.H. Encyclopedia of Intensive Care Medicine. 2012. (p. 76)

(3) The Implications of a Tracheostomy for Discharge Destination. Scales, D.C. American Journal of Respiratory and Critical Care Medicine. 2015. https://www.atsjournals.org/doi/full/10.1164/rccm.201505-1007ED

(4) Fracture and aspiration of a tracheostomy tube. Loh, T.L., Chin, R., Flynn, P. & Jayachandra, S. BMJ Case Report. 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3931958/

(6) Can Tracheostomy Improve Outcome and Lower Resource Utilization for Patients with Prolonged Mechanical Ventilation? Yuan, C.R, Lan, T.Y & Tang, G.J. Chinese Medical Journal. 2015. https://journals.lww.com/cmj/fulltext/2015/10050/Can_Tracheostomy_Improve_Outcome_and_Lower.10.aspx

(7, 12) Tracheostomy: from insertion to decannulation. Engels, P.T., Bagshaw, S.M., Meier, M. & Brindley, P.G. Canadian Journal of Surgery. 2009. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769112/

(8, 9) Late Complications of Tracheostomy. Epstein, S. K. Respiratory Care, Vol. 50. 2005.  

(10, 11) Trends in Tracheostomy for Mechanically Ventilated Patients in the United States, 1993–2012. Mehta, A.B., Syeda, S.N., Bajpayee, L., Cooke, C.R, Walkey, A.J. & Wiener, R.S. American Journal of Respiratory and Critical Care Medicine. 2015. https://www.atsjournals.org/doi/10.1164/rccm.201502-0239OC

(13) Tracheostomy must be individualized! Pelosi, P. & Severgnini, P. Critical Care. 2004. https://ccforum.biomedcentral.com/articles/10.1186/cc2966

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