Tracheotomy

Tracheotomy (or tracheostomy) is a surgery in which a hole is made to the front of the neck into the trachea (windpipe). Through this opening, a curved tube is introduced into the trachea that allows breathing from the throat so air gets in and out of the windpipe and the lungs without passing through the nose and mouth. In addition to acting as an airway, the tube also allows the removal of lung secretions.

Trachea is a tube-like, cartilaginous structure located in the front region of the neck, below the larynx (voice box). As it reaches the chest, trachea divides into two branches – the right and left bronchi, leading to the lungs.

The terms tracheotomy and tracheostomy are used synonymously; however, tracheotomy is the incision or cut made to the trachea that creates a temporary or permanent opening for air exchange and the opening is called tracheostomy.

Tracheotomy can be of two types – non-emergency and emergency. Non-emergency tracheotomy is performed by open/conventional technique or percutaneous dilational technique. Emergency tracheotomy is a life-saving procedure that is done as an open surgery or cricothyroidotomy.

A tracheostomy may be advised in the following cases:

• Need for ventilators over long periods or prolonged intubation, which may lead to damage to the larynx and trachea
• To clear lower respiratory tract secretions
• Upper airway blockage due to:
  • Trauma or obstruction of the larynx 
  • Tracheal obstruction
  • Inflammatory disease
  • Benign or malignant tumours in the larynx or trachea
• Where the use of a laryngeal mask airway (to keep airways open) is not recommended.
• For difficult airway management, where endotracheal intubation (tube is introduced through the nose into the trachea) is not possible.
• Treacher Collins and Pierre Robin syndrome (congenital inherited disorders in which facial bones and tissues are not fully developed)

An emergency tracheotomy is performed when a person experiences an airway emergency (obstruction to the airway) that cannot be managed with any other options.

Generally, tracheostomy will be removed once regular breathing is possible for a person. However, persons who have permanent damage to the larynx or pharynx (that helps in swallowing) will need a permanent tracheostomy to help them breathe. A tracheostomy may affect eating and drinking and speech. So, speech therapy may be advised in such individuals.

The contraindications for tracheotomy include:

• An individual whose health status is unstable
• Infections on the neck wall

Relative contraindications in which the procedure can be done, but with caution, include:

• Abnormal anatomy or a history of neck surgeries
• Poor neck mobility
• Unusually prone to bleeding
• Unusual origins or course of blood vessel
• Emergency access to the airway 
• Morbid obesity with short neck
• Cervical spinal injury
• Clotting disorder
• Individuals requiring high ventilation support 
• Infection in the soft tissues of the neck

In an emergency tracheotomy, there may not be any time for preparations. However, when the tracheotomy is done as a planned procedure, the following pre-surgical preparations are done. 

• Your doctor will conduct a physical examination before the procedure to check if you are fit enough for the surgery.
• You may be advised to get some diagnostic tests done such as blood tests prior to the procedure.
• Inform your doctor if you are or think you are pregnant. Also, tell him/her if you are allergic to anything such as medicines, contrast dye, or medicines given for anaesthesia.
• If you smoke, your doctor may ask you to stop smoking at the earliest before the procedure to help prevent complications and allow for a faster recovery.
• Inform your doctor if you take any blood-thinners, painkillers, anti-inflammatory medications, herbal supplements, or cancer medications. You will be advised on how to continue with these medications before your surgery.
• Tell your doctor if you have shortness of breath while sleeping.
• Avoid eating after midnight the day before the surgery. You will be allowed to drink water until two hours before the surgery.
• You will have to sign a consent form before the procedure. The form will give your approval for the procedure.

When the tracheotomy is a scheduled procedure (and not an emergency), you will be admitted to the hospital and asked to change into a hospital gown. In the operating room, you will be asked to lie down with a shoulder roll under your neck, which allows for stretching the neck.

The types of tracheostomy include:

Conventional or open neck tracheostomy

The operation will be performed under general anaesthesia, which will make you sleep during the surgery.

• The surgeon will make a small, horizontal opening in your skin on the front of your neck.
• He/she will separate the muscles in this area and move them to a side until the trachea (windpipe) and the thyroid gland are seen.
• The surgeon will then pull up the thyroid gland or remove it during the surgery.
• He/she will cut your trachea open vertically or horizontally and create a flap with the tracheal cartilage. Alternatively, the surgeon will remove a section of the anterior wall of your trachea to create a small opening.
• Next, the surgeon will introduce a tracheotomy tube through this opening. He/she will verify the correct placement of the tracheotomy tube through the ease of air exchange, visually checking the placement, and oxygen saturation and exhaled carbon dioxide levels.
• The tube will be kept in place with two sutures on each side, followed by a tracheotomy tape.

Percutaneous dilational technique (bedside tracheotomy)

Bedside tracheotomy is a minimally invasive procedure done under general anaesthesia. In this procedure, the tracheotomy tube is inserted without directly visualising the trachea in an individual who has an endotracheal tube inserted.

• You will be asked to lie down with your neck in an extended position.
• The surgeon will make an incision in the front of your neck and move aside the tissue above the trachea.
• He/she will withdraw the endotracheal tube such that its cuff is at the same level as the glottis (the vocal apparatus that contains the vocal cords).
• Next, the surgeon will insert a fiberoptic bronchoscope through the endotracheal tube so that the light from its tip is seen from the incision.
• The surgeon will examine your trachea by touching the skin above the area He/she will determine the position of entry into the trachea through the bronchoscope light that will be seen through your skin.
• Your doctor will insert a Teflon catheter introducer needle in an appropriate position in the trachea taking care not to injure the back wall of the trachea.
• Once that is done, the surgeon will remove the needle, and dilate its path into the trachea with the help of a dilator. A tracheostomy tube will then be inserted over the dilator.
• The surgeon will check the placement of the tube, and tie the tube in place with sutures on your skin and a tracheostomy tape.

Emergency tracheostomy: 

This can be done by two methods – open tracheostomy or cricothyroidotomy.

Open tracheostomy:

This is performed as described above to gain urgent access to the airway.

Cricothyroidotomy: For this procedure an opening is made to the cricothyroid membrane (the membrane covering the cricoid cartilage that lies in front of the thyroid), as this membrane is closest to the surface of the skin, and less dissection is required.

• The surgeon will locate your cricothyroid membrane, insert a knife into the membrane and then twisted vertically to open the membrane. He/she will then place an endotracheal tube in the opening.
• When your condition stabilises or if breathing support is needed for more than 2-4 days, then a conventional tracheostomy is performed.

The doctor will remove the tube when it is no longer required and you are able to breathe on your own. The opening does not need to be stitched as it will heal on its own. Once the tube is removed, a bandage will be placed over the opening. In about two weeks, the opening should close.

You will stay in the hospital for three to five days. You can expect the following when you wake up after the surgery:

• You will have a humidity collar in front of the tracheostomy tube to provide moisturised air rich in oxygen.
• You will have feeding tubes through your nose for food until you can eat.
• Antibiotics may be given to reduce the risk of infection.
• A healthcare practitioner will take your chest X-ray to ensure that the tube is in place and there are no complications. The tracheostomy tube will be changed 7 days after surgery.
• Before discharge, you will be shown how to clean the catheter, manage the suction within the tube, clean the skin around the tracheostomy site, and humidify the air you breathe in.
• You may communicate with others by writing, as your speech may be slightly affected. A speech therapist will help you learn to speak.
• You may require training for swallowing, chewing, and breathing with the tube in place. Nutritionists may help in this process.

You may require the following care at home:

• In case of tracheotomy tube removal, the dressing should be changed two times a day or as it gets soiled. Before changing the dressing, use moist gauze to clean the site.
• Place a finger over the opening while coughing or talking. This encourages the site to close.
• Use a cover for the tracheotomy tube to protect the airways from dust and other environmental elements.
• Avoid soaking in water. Swimming is not advisable with the tube in place or even after it is removed until the area has healed.
• While showering, ensure that the water does not go into the tube.
• It is important to have a humidifier while sleeping at night. It keeps the secretions moist and loose and does not allow them to clog the tube.
• Stay mobile and active after surgery. Though vigorous activities must be avoided for six weeks after the surgery.
• Daily activities can be resumed depending on your ability to breathe without any breathing support.
• Warm compresses should be applied to reduce pain at the surgical opening.
• The area should be kept clean and dry. Cover the opening with a scarf while outdoors.

When to see the doctor?

You should visit a doctor if you experience:

• Trouble breathing that does not ease after clearing your secretions
• Discomfort and pain, even a week after the procedure
• Abnormal heart rate
• Vomiting after drinking or eating
• Noisy breathing during the day or night
• Trouble swallowing
• A tracheotomy scar that is painful and feels like a bump
• A weak, hoarse, or whisper quality in voice, lasting longer than seven days after surgery

The complications of a tracheostomy are classified as early and late complications.

Early complications include:

• Repeated nerve injuries
• Bleeding 
• Wound infection
• Damage to the cricoid cartilage (cartilage at the start of the trachea)
• A hole created between the trachea and oesophagus during surgery
• Blockage of the tracheostomy tube
• Lung collapse
• Air leaks in the space between the lungs due to trauma 
• Air trapped under the skin

Late complications include:

• A small area of inflammation
• Narrowing and blockage of the passage of the trachea and larynx
• Contents of the stomach come up into the airways
• Narrowing of the area of the trachea just below the vocal fold
• An abnormal connection between the oesophagus and trachea
• Tracheal collapse due to softening of the cartilage that keeps the airway open

A follow-up visit with your doctor will be arranged as per the doctor’s discretion.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.