Reading Time:

8 minutes

Tracheostomy Common Questions

A tracheostomy is a medical intervention in which specialists introduce a tube inside the body to provide a breathing airway, through an incision on the air passage from the throat to the lungs. “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

In some cases, doctors perform a tracheostomy when an obstruction blocks the respiratory tract to temporarily regain the ability to breathe.  Sometimes, patients with a lasting injury in the voice box might need a tracheostomy for a long time. Therefore, according to the type of medical condition, patients can have a long-term or short-term tracheostomy.

Why is a tracheostomy done?

 Various circumstances may require a tracheostomy. These are, classified as non-emergency and emergency situations.

  • Non-emergency situations. Doctors will perform a tracheostomy before surgeries that compromise the respiratory system to provide a temporary breathing airway.
  • Emergency situations arise when an obstruction in the respiratory tract prevents the individual from breathing properly. This situation frequently involves using a respirator and inserting a tube into the airways from 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 were performed on the battlefield in antiquity and remains a common indication today.”2

Specialists recommend performing a tracheostomy to certain hospitalized patients with breathing problems. “Tracheostomies are commonly provided to the 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 based 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

After a successful procedure. the patient must rest in the healthcare facility for 5 days only. Consider that it might take time to get used to breathing and speaking with the trach tube. A thorax radiography ensures that the trach tube is in the right position. In certain instances, doctors recommend medication after a tracheostomy to avoid the development of damaging organisms.

Aside from taking care of yourself, also look after the trach tube.  Your physician should instruct you and your caregiver how to maintain the tube clean and hygienic.

What are the benefits of a 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

Other benefits are associated with a reduced risk of pneumonia and mortality. “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

What are the Advantages and Disadvantages of a 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, the patient might experience some postsurgical issues. A tracheostomy can lead to:

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

Issues involving the trach tube include:

  • Body fluids obstructing the tracheostomy tube.
  • The unsuccessful closure of the incision after removing the tube.
  • The displacement of the track tube

Late Complications of a Tracheostomy

 

Table 1. Late Complications of Tracheostomy
Late Complications of Tracheostomy (8)

 

“A number of mechanisms can cause late complications after tracheostomy. Complications can be directly related to the 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

Some people do not experience these issues after a tracheostomy.  Infants, smokers, and individuals in their later stages of life tend to manifest these complications. 

Is tracheostomy a common procedure? 

“Although many factors may have contributed to the 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 meta-analyses that have shown no difference in mortality or ventilator-associated pneumonia with an early tracheostomy may have decreased enthusiasm for early tracheostomy, resulting in fewer tracheostomy procedures. Alternatively, it is possible that with the 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

 

Tracheostomy use rates in the United States, 1993-2012. Left y-axis: Age-adjusted U.S. population incidence, cases of tracheostomy per 100,000 U.S. adults. Right y-axis: Tracheostomy use rates as a percentage of all patients receiving invasive mechanical ventilation (MV). (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 a 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, a 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 a percutaneous technique is superior to any other, but the 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

Tracheostomy is a significant and lifesaving procedure for patients with upper airway obstruction. If you had this intervention, whether it is a short-term or long-term tracheostomy, follow your doctor’s directions to avoid any adverse outcome.

 

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 

 

María Laura Márquez
13 October, 2018

Written by

María Laura Márquez, general doctor graduated from The University of Oriente in 2018, Venezuela. My interests in the world of medicine and science, are focused on surgery and its breakthroughs. Nowadays I practice my profession...read more:

Leave a Reply

If you would also like a response sent to your email please add it in the email box below.