Tracheostomy

• Tracheostomy is a surgical procedure used to create an opening in the neck for direct access to the trachea (the breathing tube).
• Tracheostomy is performed because of airway obstruction, problems with secretions, and inefficient oxygen delivery.
• Tracheostomy can have complications.
• A tracheostomy requires follow-up care.

A tracheostomy is a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube.

A tracheostomy is usually done for one of several reasons:

1. to bypass an obstructed upper airway (an object obstructing the upper airway will prevent oxygen from the mouth to reach the lungs);
2. to clean and remove secretions from the airway;
3. prolonged mechanical ventilation (breathing machine); and
4. to more easily, and usually more safely, deliver oxygen to the lungs.

It is important to understand that a tracheostomy, as with all surgeries, involves potential complications and possible injury from both known and unforeseen causes. Because individuals vary in their tissue circulation and healing processes, as well as anesthetic reactions, ultimately there can be no guarantee made as to the results or potential complications.

Tracheostomies are usually performed during emergency situations or on very ill patients. This patient population is, therefore, at higher risk for a complication during and after the procedure

The following complications have been reported in the medical literature. This list is not meant to be inclusive of every possible complication. It is listed here for information only in order to provide a greater awareness and knowledge concerning the tracheostomy procedure.

• Airway obstruction and aspiration of secretions (rare).
• Bleeding. In very rare situations, the need for blood products or a blood transfusion.
• Damage to the larynx (voice box) or airway with resultant permanent change in voice (rare).
• Need for further and more aggressive surgery
• Infection
• Air trapping in the surrounding tissues or chest. In rare situations, a chest tube may be required
• Scarring of the airway or erosion of the tube into the surrounding structures (rare).
• Need for a permanent tracheostomy. This is most likely the result of the disease process which made the tracheostomy necessary, and not from the actual procedure itself.
• Impaired swallowing and vocal function
• Scarring of the neck

Many of the types of patients who undergo a tracheostomy are seriously ill and have multiple organ-system problems. The doctors will decide on the ideal timing for the tracheostomy based on the patient's status and underlying medical conditions.

In most situations, the surgery is performed in the intensive care unit or in the operating room. In either location, the patient is continuously monitored by pulse oximeter (oxygen saturation) and cardiac rhythm (EKG). The anesthesiologists usually use a mixture of an intravenous medication and a local anesthetic in order to make the procedure comfortable for the patient.

The surgeon makes an incision low in the neck. The trachea is identified in the middle and an opening is created to allow for the new breathing passage (tracheostomy tube) to be inserted below the voice box (larynx). Newer techniques utilizing special instruments have made it possible to perform this procedure via a percutaneous approach (a less invasive approach using a piercing method rather than an open surgical incision).

The surgeons will monitor the healing for several days after the tracheostomy. Usually, the initial tube that was placed at the time of surgery will be changed to a new tube sometime between 10 and 14 days following surgery, depending on the specific circumstances. Subsequent tube changes are usually managed by the treating physician or nursing staff.

Speech will be difficult until the time comes for a special tube to be placed which may allow talking by allowing the flow of air up to the vocal cords. Any time a patient requires mechanical ventilation, air is prevented from leaking around the tube by a balloon. Therefore, while the patient is on a mechanical ventilator, he/she will be unable to talk. Once the doctors are able to decrease the-size of the tube, speaking may be possible. At the appropriate time, instructions will be given. Oral feeding may also be difficult until a smaller tube is placed.

If the tracheostomy tube will be necessary for a long period of time, the patient and family will be instructed on home care. This will include suctioning of the trachea, and changing and cleaning the tube. When the time comes you will be provided with ample information, instruction, and practice. Often, home healthcare will be provided, or the patient will be transferred to an intermediate health care facility.

In some cases (especially when performed during an emergency or prolonged intubation) the tracheostomy will not be a permanent situation. If the patient can tolerate breathing without the tracheostomy tube the surgical site can be closed, leaving a scar at the outside of the neck.