What is a Tracheostomy?
A tracheostomy is an opening through the front of the neck into the trachea – the windpipe – to assist with breathing. The surgical process of creating a tracheostomy is called tracheotomy, though the words are sometimes used interchangeably.
Why Might Someone Need a Tracheostomy?
A tracheostomy is created to give access to the airway and lungs when normal breathing is compromised. It may be for emergency or short-term management of breathing problems, for example in an intensive care unit, or can be a long-term solution for people who need continued mechanical ventilation.
Tracheostomies are used when a person is unable to breathe effectively. This could be due to a number of conditions, including high spinal cord injuries, motor neurone diseases, or head injuries. Short-term breathing difficulties in an unconscious person after trauma are sometimes managed with a ventilation tube in the throat, but a tracheostomy is a much safer longer-term solution.
Another reason why someone may need a tracheostomy is due to a blockage in their upper airway. This could be an emergency treatment for an acute condition such as anaphylaxis (serious allergic reaction) where the throat swells up so much that it blocks the airways, or if someone is choking on something that cannot be quickly removed. Some cancers of the mouth and throat can also impede normal breathing so sometimes tracheostomies are created as part of cancer treatment.
Some tracheostomies are only used for suction to remove secretions in the lower airways if they are causing significant breathing problems and cannot be removed with less invasive methods such as cough assist devices.
Preparing for a Tracheostomy
If a tracheotomy is a planned procedure with a general anaesthetic – a procedure where you are put to sleep for the operation – you will usually be advised to stop eating and drinking several hours beforehand. People who take blood-thinning medication will also need to stop the medication for a period of time before the procedure to reduce the risk of bleeding. The length of time will depend on the type of blood thinner, and sometimes the reason for taking it.
Occasionally, tracheotomy is performed without general anaesthetic, but medications will be administered to make you feel more relaxed. Local anaesthetic will also be injected at the incision site so that it shouldn’t feel painful.
The doctors and nurses looking after you will make sure you are prepared for the procedure and understand what is happening. They will provide a theatre gown and identification, put a cannula into a vein in your arm or hand for intravenous medication, and take blood tests and routine observations.
How is a Tracheostomy Performed?
A tracheotomy is a small surgical incision made into the skin and tissues at the front of the neck to create an opening into the air passages. The cut is made carefully between the muscles in the neck and through the front of the trachea. The trachea or windpipe has bands of cartilage, the same semi-rigid material as tendons – which helps it maintain its structure. The placement of the tracheostomy is chosen to do as little damage to the structures of the neck and throat as possible.
When the hole has been made, a small tube is inserted and held in place with a strap. A flat front piece on the tube stops it from going too far in. Some types of tracheostomy have a small donut-shaped balloon on the inside which can be inflated once the tube is in place to hold it steady.
Potential Risks and Complications of a Tracheostomy
Any medical procedure carries some risk of complication, and a planned procedure should be carefully explained and risks and benefits discussed. When a tracheostomy is performed in an emergency, it is not always possible to fully discuss the risks first, and a medical team may have to make the decision to perform the procedure in the presumed best interests of the unwell person.
The risks of a tracheotomy procedure are largely the same as any medical procedure involving an incision (cut) through the skin; there is a chance of bleeding, infection, and a small chance of unintended damage around the incision site. Occasionally, a surgical procedure on the respiratory organs can cause a pneumothorax – a condition where air collects outside the lung and reduces the space for the lung to expand into. If this happens, it will be closely monitored; a small pneumothorax will often resolve without treatment, whereas a larger collection of air may need to be drained.
The tracheotomy is performed with either general or local anaesthetic, so the initial procedure should be painless. When the anaesthetic wears off and the wound is healing, it is normal to feel some pain. Your medical team may prescribe painkillers for those early stages of healing.
Common risks of living with a tracheostomy in the longer term include infections at the site or in the lungs and a blocked tube. With good tracheostomy care and strict hygiene practices, these complications can usually be avoided. Rarer complications may include narrowed airways due to scar tissue, or a weakened windpipe that’s unable to fully support the tracheostomy tube.
Types of Tracheostomy Tube
There are several types of tracheostomy tube, and the most suitable type depends on the intended use.
Cuffed Tracheostomy Tubes
One of the main differences between different tracheostomy tubes is whether they are cuffed or uncuffed. The ‘cuff’ refers to a small balloon on the part of the tube that stays within the trachea. The balloon is inflated with water or air after insertion to hold the tube in place and prevent leakage of air or oxygen above the position of the tracheostomy. This is necessary when the tracheostomy is used for positive pressure ventilation – i.e. when a mechanical ventilator is used to push air into the lungs.
Most cuffed tracheostomy tubes have a set distance between the flange and the cuff which may not be suitable for people with unusually large necks due to obesity or swelling. Tracheostomy tubes with adjustable flanges have been developed to allow for a variable gap between the surface of the front of the neck and the inside of the trachea.
Uncuffed Tracheostomy Tubes
An uncuffed tube does not have the balloon and is instead held in place by a neck strap. These tubes allow gas to escape above the airway and so are not suitable for artificial ventilation. However, it can be used for suctioning to help clear secretions. This type of tube is often recommended for people who are going home with a tracheostomy tube for suction but can breathe independently.
A cuffed, fenestrated tube is another option for people who breathe most or all of the time through their nose and/or mouth
Fenestrated Tracheostomy Tubes
A fenestrated tube has small open windows along the length of the tube which allows a person to breathe partially through their nose and mouth even while the tube is in place. This means that using a fenestrated tracheostomy tube may allow a person to preserve their ability to speak and to cough effectively.
The main disadvantage of a fenestrated tracheostomy tube is that people who are at risk of aspiration peumonia – a type of pneumonia where fluids and matter from the digestive tract can enter the airways – are less protected from aspirating as compared to a cuffed tracheostomy tube. If someone needs to be ventilated through a fenestrated tube, the tubes have an insert which covers the fenestrations (windows). Air that’s introduced through the tube is then prevented from escaping to the upper airways, allowing for effective ventilation. The non-fenestrated inner tube is also used for effective suctioning.
Single or Double Cannula Tracheostomy Tubes
‘Single cannula’ tracheostomy tubes are usually for short-term use only; these are a simple single lumen tube. A ‘double cannula’ tube is recommended for longer-term use as it has an inner liner which can be easily removed for cleaning, preventing the tube from becoming clogged or blocked.
People who have mechanical ventilation all or most of the time may have devices to ensure that the air or oxygen they breathe through the tracheostomy is kept moist and warm. Some tracheostomy attachments also have a fine filter.
Effective suctioning is an essential part of tracheostomy care so people with a tracheostomy will need a suction machine – a pump with a fine tube to suck any secretions from the tube and the trachea. Some may also have secretions above the level of the tracheostomy which need to be suctioned. The suction equipment includes tubing, a container that collects anything sucked out of the airways, and one or more different types of suction catheter – the end of the tube that can be introduced into the airways. These parts of the suction equipment are disposable and should be changed frequently, therefore it is necessary to have spare tubing and suction vessels at home.
A ventilator, tubing and connections can be quite bulky and going home with mechanical ventilation will mean having a dedicated space for equipment. Some people have ventilator machines which introduce room air, while others need additional oxygen and may use a combination of oxygen tanks and machines which concentrate oxygen from the air and deliver a set percentage and flow rate. People who are completely dependent on mechanical ventilation for all their breathing should usually have duplicates of most equipment.
Some ventilator and suction equipment are mains powered and only suitable for use within the home, but smaller portable units with rechargeable batteries are also available for travel and use outside of your home.
If you are planning to go home with a tracheostomy, you and your family members or caregivers who will be involved in managing your tracheostomy should be given some education and practice with the day-to-day management of your tracheostomy. Different types and brands of the tube are all slightly different but should fit standard equipment for ventilation, cleaning, and changing.
Keeping tracheostomies and any related equipment meticulously clean is an important part of tracheostomy care. People with tracheostomies have a higher risk of chest infections, especially if their ability to cough and clear any moisture on their lungs is reduced. Reducing the amount of dust and debris that can enter a tracheostomy is important, and wearing a specially designed filter or even placing a thin, clean cloth over the opening can help.
Tracheostomies can easily become clogged with secretions from the lungs and should be cleaned regularly, sometimes several times a day. Suction equipment can help clear secretions from the tracheostomy tube and the windpipe.
Living with a Tracheostomy
Having a tracheostomy does not mean that you cannot eat and drink normally, unless the original reason for the tracheostomy also affected your ability to swallow. This may happen in the case of certain spinal cord injuries or cancers of the throat. Some people also find that having a tracheostomy alters the sensation of swallowing, which may take some getting used to.
People with long-term tracheostomies usually have a limited ability to speak; speech is formed by the passage of air across the vocal cords, but a tracheostomy incision is made below the vocal cords and so air normally bypasses the vocal cords. Valves are available to make it easier to speak when you have a tracheostomy, but they may not be suitable for everyone. Don’t hesitate to reach out to a speech therapist if you need support with communication.
People who have tracheostomies for long-term mechanical ventilation are often able to continue living at home with support for their extra respiratory needs. Some people are entirely dependent on mechanical ventilation for all their breathing and clearing secretions from their chest. For them, any delay or malfunction in their ventilator would quickly become critical, and so they will likely need 24-hour support. This would traditionally be in a formal care setting, but with the right care support, more and more people are now able to live at home even with significant medical and care needs.
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