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Understanding Tracheostomy and What to Expect After the Procedure

 

What is Trachea?

The trachea - your windpipe - runs anteriorly (superiorly) to your food pipe, placed centrally and in mid-line in the neck, and is an integral part of your respiratory system. It is joined proximally to your oropharynx (throat) and distally divides to form two smaller pipes (the bronchi) that enter the respective lungs. It is supported by cartilaginous rings that prevent it from collapsing. Acute or chronic conditions that affect the trachea can impair smooth gaseous exchange and prevent sufficient oxygen from entering the lungs due to obstruction.

Trachea

Figure 1

 

What is a Stoma?

Anatomically speaking, a stoma is an opening in a hollow viscus. Just like your nose, mouth, anal or urethral orifice are natural stomas (or openings) into certain organ systems, we can also create artificial openings in the respective organs to assist with diagnosis, treatment, or palliative care. Stomas are most commonly created in the gut (colostomy, ileostomy, percutaneous gastrostomy), renal system (nephrostomy, vesicostomy) or in the respiratory system (tracheostomy).

 

What is Tracheostomy?

A Tracheo-Stomy refers to two words - the trachea and the stoma. It is either a temporary or a permanent opening created through the trachea to allow adequate gaseous exchange. The indications include tracheomalacia (collapse of trachea/tracheal rings), obstructing tumors (e.g., esophageal tumor, laryngeal tumor), a foreign body stuck in the trachea, tracheal stenosis secondary to chemical/mechanical injury or clearing secretions from airway. However, the most common is the need for prolonged mechanical ventilation (approximately accounting for 2/3rd of the tracheostomies)

Trachea

Figure 2

 

What are the symptoms of Acute Tracheal Obstruction?

With tracheal obstruction, a person may experience the following signs and symptoms:

         Difficulty breathing or shortness of breath

         Stridor - a whistling or squeaking sound during inspiration (inhalation)

         Noisy breathing

         Hoarseness

         Bluish skin tone or cyanosis

         Coughing or trouble swallowing

         Coughing up blood

These symptoms are particularly alarming if they evolve quickly over a couple of hours. The pediatric age group is particularly prone to ingesting a foreign body thus, one needs to seek medical treatment immediately whenever these symptoms appear.

 

What Medical Conditions require a Tracheostomy?

All tracheostomies are performed due to acute respiratory failure or lack of air reaching the lungs. There are a range of reasons why lungs are unable to get sufficient oxygen.

1.    Need for prolonged mechanical ventilation

2.    Clearing secretions from the airway

3.    Anaphylaxis

4.    Foreign body obstruction

5.    Birth defects or tumors like cystic hygroma

6.    Laryngectomy or laryngeal injury

7.    Severe mouth or neck injuries

8.    Infection, like croup or epiglottitis

9.    Laryngeal injury or spasms

10.  Vocal cord paralysis (VCP)

11.  Airway burns from corrosive material inhalation (e.g., smoke or steam)

12.  Subglottic stenosis

13.  Subglottic web

14.  Tracheomalacia (tracheal collapse)

15.  Oedematous tongue or small jaw blocking airway

16.  Treacher Collins and Pierre Robin Syndromes

17.  Obstructive sleep apnea

18.  Neuromuscular disorders, weakening or paralyzing chest muscles and diaphragm

19.  Aspiration due to weakened muscles or sensory problems in the throat

20.  Cervical vertebral fracture with injury of spinal cord

21.  Long-term unconsciousness or coma

 

How is a Tracheostomy Performed? (Different Types of Tracheostomies)

Traditionally performed in an operating room, tracheostomy requires general anesthesia, making the patient unaware of the surgical procedure. However, in high risk patients or those unfit for GA, tracheostomies can be performed under local anesthetic that numbs the neck and throat. When airway is suspected to get compromised from GA or if the procedure is done outside the operating room, LA is used.

Trachea

Figure 3

 

The type of tracheostomy you undergo relies on the indication of the procedure and whether the procedure was planned. It has to be either one of the two:

         Surgical tracheotomy requires operating room or hospital room as the procedure setting. The surgeon typically makes a horizontal incision through the skin at the lower-most anterior part of neck. The incision is extended into the muscles and they're subsequently pulled back, a small portion of the thyroid gland (that sits anteriorly to the trachea) is cut, uncovering the windpipe (trachea). The surgeon creates a tracheostomy hole at an anatomically-determined point on your windpipe near the base of your neck.

         Minimally invasive tracheotomy (percutaneous tracheotomy) is usually performed outside OR, or inside a hospital room. A small incision is made near the base of the neck anteriorly. A special lens is introduced through the mouth to allow adequate view of the inside of the throat. A needle is inserted under guided view of the lens into the windpipe to create the tracheostomy hole. The hole is then expanded to fit the adequate size of the intended tracheostomy tube.

 

The common denominator for both procedures is insertion of a tracheostomy tube into the windpipe. To prevent it from slipping out of the hole, a neck strap can be used that attaches to the face plate of the tube. Temporary sutures are sometimes used, securing the faceplate to the neck's skin. You can shop for Dale Medical Tracheostomy Tube Holder here.

Trachea

Dale Medical Tracheostomy Tube Holder

 

Insertion of Tracheostomy Tube

In a conventional surgical procedure, after sedation, a local anesthetic such as xylocaine will be used to numb the area where the stoma will be performed. Typical tracheostomy incision ranges from 3-4 cm and is made anteriorly and centrally in the patient's neck using instruments like an introducer needle, bronchoscope, and a dilator.

 

Placement of Tracheostomy Tube

Tracheostomy tubes are conventionally placed at the level of 2nd or 3rd tracheal rings. The stoma should be large enough to occupy 65-75% of the patient's tracheal diameter.

 

Types of Tracheostomy Tubes

Trachea

Figure 4

There are a range of tracheostomy tubes available in the market. Choosing the right one requires an appropriate understanding of the patient's needs as well as intended purpose of available tracheostomy tubes. For starters, you need to know if a cuffed or uncuffed tube should be used, whether it should have an inner tube, and if it needs to be fenestrated or non-fenestrated.

 

Let's explore some of the most commonly available styles of tracheostomy tubes:

         Cuffed and uncuffed tracheostomy tubes

         Tracheostomy tubes having disposable OR reusable inner cannulas

         Fenestrated tracheostomy tubes (tubes having a hole above the cuff that allow easy speaking or weaning from tube)

         Tracheostomy tubes having a proximal increased length (traditionally find their use in neonatal or pediatric population with need for prone positioning)

         Tracheostomy tubes having distally increased lengths (particularly useful in conditions that require a tracheostomy tube with extended lengths, like stenosis or tracheomalacia)

         Customized tracheostomy tubes - particularly designed for patients requiring tracheostomy tubes with specific dimensions and functions

         A fenestrated tube, simply put, comes with a hole. Having a hole on the outer cannula, a fenestrated tracheostomy tube allows speech by allowing air movement through the patient's mouth and nose. However, you can still lock off the opening with a non-fenestrated inner cannula.

         Cuffed tracheostomy tubes (such as Teleflex Medical Endotracheal Tube Sheridan) are much like ETT's in the adult, and come with an inflating soft balloon at the end, allowing for complete sealing of the airway. These tubes find their use in patients with positive pressure ventilation (PPV) or who are at increased risk of aspiration due to excessive oral or gastric secretions.

Trachea

         Naturally, as the name indicates, the uncuffed tubes do not come with cuff defined above at their end. That's why they can only be prescribed in patient with adequate gag and cough reflex, who can sufficiently and independently clear airway secretions and thus, would not aspirate. These tubes find their use in longer-term patients and positive pressure ventilation is not a possibility using this type of tube. Betty Mills offers a range of Uncuffed Tracheostomy including Medtronic Tracheostomy Tube Shiley Long Size 6.5. 

Trachea

         Transferring a patient out of the critical care unit requires shift to a double lumen uncuffed tube. The tube allows for clearing of airway secretions should they occur. The cuff will not be unnecessarily inflated upon the tube blockage.

 

What are the Risks Associated with Tracheostomy?

Conventionally speaking, tracheostomy is a relatively safe procedure. However it doesn't come without risks. Complications can be intra-operative, in the early or late post-operative period. The risk rises to two-folds when the tracheotomy is undertaken in an emergency setting rather than as an elective procedure.

Intra-operative complications include:

1.    Hemorrhage

2.    Tracheal, thyroid or nerve injury in the neck

3.    Misplacement (and later displacement) of the tube

4.    Subcutaneous emphysema - that is air trapped in tissue under the skin of the neck. It can result in breathing problems and incur tracheal or esophageal damage

5.    Pneumothorax - due to puncture of pleura and resulting in air buildup between the chest wall and lungs. It results in rapid deterioration of lung function and causes lung collapse

6.    Hematoma formation - hemorrhage between the neck structures can result in buildup of blood resulting in pressure on adjacent structures

Post-operative (long-term) complications - most likely occurring with a tracheostomy in situ for extended periods - include:

1.    Tracheostomy tube obstruction

2.    Tracheostomy tube displacement

3.    Injury, fibrosis or stenosis of the trachea

4.    Development of trachea-esophageal fistula, an abnormal communication between air and food passages, significantly increasing the risk for aspiration pneumonia

5.    Tracheoinnominate fistula -an abnormal communication between the trachea and the innominate artery supplying the right upper limb as well as the head and neck - resulting in fatal hemorrhage

6.    Infection extending into the trachea and bronchial tubes (tracheobronchitis) or lungs tissue (pneumonia)

People that leave the hospital with a tracheostomy in place, they need regularly scheduled visits with their care provider for monitoring potential complications. They will also be instructed about the warning signs and when they should call their doctor, for example:

1.    Hemorrhage from the tracheostomy tube or from the trachea

2.    Shortness of breath or difficulty breathing

3.    Pain at the site of tracheostomy

4.    Edema or redness around the tracheostomy site

5.    Apparently displaced tracheostomy tube

 

What to Expect After a Tracheostomy?

Once you get done with a tracheostomy, you will be required to stay in the hospital for at least a few days. Your medical team will help you understand the dynamics of your tracheotomy tube and how to care for it once you leave:

 

Cleaning and suctioning. You'll need to know how to clean the tube with sterile techniques and appropriate suctioning to avoid complications like irritation and infection. For suctioning, you may be required to learn to use a special machine that vacuums debris from your tube. Shop for Carefusion Tracheostomy Care Kit AirLife Sterile here.

Trachea

 

Ability to Speak. Following a tracheostomy, you probably won't be able to retain your pre-tracheostomy speech function. Depending upon the type of tracheostomy, some patients are not able to talk at all. A speech therapist or someone else from your medical team may acquaint you with techniques or devices that help you communicate. A particularly useful device that assists people with tracheostomy for speech is Cardinal Health Shiley™ Speaking Valve.

Trachea

 

Ability to Swallow. While your tracheostomy heals, surrounding inflammation makes it very hard to swallow. That's why nutrition is mostly delivered via IV route or through a nasogastric tube that delivers nutrients directly into the stomach.

Trachea

 

Lung Irritation. The air entering into your lungs may be drier since it won't pass through your moist nose or nasal hairs. Disturbance of this physiological phenomenon can irritate the tissue in the airway and cause increased mucus secretion and coughing. You medical team will teach you how to use humidifiers, saline solution, and other techniques to help deal with the irritation and expectorate the mucus.

 

Happy Shopping!

If you can't find the tracheostomy-related product that you were looking for, give us a call at 1•800•238•8964. One of our representatives will be happy to assist you!

 

External Image References:

Fig 1: https://i0.wp.com/post.medicalnewstoday.com/wp-content/uploads/sites/3/2020/02/Trachea_ver2-scaled.jpg?w=1155&h=5376

Fig 2: https://www.sciencedirect.com/science/article/pii/S2090074016300585

Fig 3:https://www.practostatic.com/health-wiki/images/ed9e1503f7e2ae617b4ea94ce6d6b787.jpg

Fig 4: https://www.respiratorytherapyzone.com/wp-content/uploads/2020/09/Fenestrated-vs-Non-Fenestrated-Tracheostomy-Tubes-Vector.svg