A tracheostomy is a surgical procedure which creates an opening in the neck, at the front of the windpipe. A tube is inserted into the opening to assist with breathing. This can then be hooked up to an oxygen supply and ventilator as required.
Fluid that builds up in the trachea can be removed through the opening.
Why have a tracheostomy?
A tracheostomy will be required when a person cannot breathe normally because of an underlying health condition or a blockage on one of their airways. It will deliver oxygen to the lungs when they are suffering respiratory failure, it can bypass an airway that has become blocked, and can remove fluid that has built up in the upper airway.
Many conditions can lead to respiratory failure, such as:
- Being unconscious or in a coma as a result of a severe head injury or a stroke
- Being paralysed with a serious neck or spinal cord injury
- A condition that causes extensive damage to the lungs such as cystic fibrosis or pneumonia
- Or a condition that causes progressive damage to the nervous system such as motor neurone disease or Guillain-Barre syndrome
The airways can become blocked through:
- Accidentally swallowing something that gets stuck in the windpipe such as a bone
- An injury, burn, infection or severe allergic reaction that causes the throat to become swollen and narrowed
- A cancerous tumour that blocks one or more airways such as mouth cancer or thyroid gland cancer
- Birth defects that cause abnormal narrowing of the airways.
Fluid can build up in the airways when the person:
- Can’t cough properly because of muscle weakness, paralysis, or chronic pain
- Has a serious lung infection such as pneumonia
- Or has an injury that causes the lungs to fill with blood.
Types of tracheostomy
A planned tracheostomy will be performed to help the patient to breathe because of a long term condition such as Wegener’s Granulomatosis or multiple sclerosis, and an emergency tracheostomy will be performed if someone is unable to breathe because of an injury or accident.
Most planned tracheostomy procedures are percutaneous tracheostomies and are carried out under general anaesthetic in an intensive care unit. The surgeon will make a small 2 centimetre long and use an instrument called a dilator to open a hole in the tissue and trachea. The tube is fed through the incision and guided into place with a guidewire.
The planned alternative to a percutaneous tracheostomy is an open tracheostomy. This may be the preferred method for children under 12 years old, if the patient has a tumour affecting the structure of the neck, the patient is overweight and has a very fat neck or there is an infection in the neck.
An open tracheostomy usually takes place in an operating theatre. The patient will typically be under a general anaesthetic. The surgeon cuts into the lower part of the neck, between the Adams apple and the top of the breastbone. The thyroid gland is cut or moved and the muscles parted so that an incision can be made in the wall of the windpipe. The tracheostomy tube can then be inserted through the opening.
If you are unable to breathe unaided the tracheostomy tube can be attached to a ventilator.
A dressing is usually placed around the wound and then tape or stitches will hold the tube in place. An X-ray can be taken to check that the tube is in the correct position.
An emergency tracheostomy may be needed following trauma if a person’s airway becomes blocked unexpectedly. A local anaesthetic will usually be administered but the procedure will still be very painful.
The paramedic will ensure that the patient is flat on their back and that their neck is exposed by placing a towel or something similar under their shoulders. It’s likely that the patient won’t be able to breathe unaided so they will often be connected to a ventilator.
Living with a tracheostomy
Many people learn to live with a tracheostomy permanently. They have to adapt their eating talking and exercise, and they have to get used to keeping the tube clean and free of blockages.
Vigorous activity should be avoided for the first six weeks following the procedure. While outside it is important to keep the tracheostomy opening clean and dry. It can be covered with a dressing or some loose clothing such as a scarf.
It is very difficult to speak following the procedure. Air normally passes over the vocal cords at the back of the throat when speaking, but after a tracheostomy the air escapes through the tube instead. A speaking valve can be utilised to fix this problem. This attachment to the regular tracheostomy tube closes every time you breathe out, which prevents air escaping and forces it over the vocal cords. It can take some practice to get used to talking with a speaking valve so you may be referred to a speech therapist to improve your ability to communicate.
Tracheostomy tubes need to be cleaned several times per day to stop them getting clogged with mucus or fluid.
Removing the tracheostomy
When the patient can breathe, protect their airway and clear fluids from their trachea unaided, then the tracheostomy tube can be removed. The opening will usually close on its own within a matter of days. If it doesn’t close naturally, it can be closed using stitches.
A tracheostomy is considered to be a low risk procedure but there can sometimes be complications. These include:
- Like any other surgical procedure there is a chance of blood loss. If the wound does not heal properly then the tube may have to be removed and surgery carried out to stem the bleed.
- The windpipe can become infected with bacteria which can be treated with antibiotics.
- Sometimes air can collect around the lungs and can cause them to collapse. This is known as a pneumothorax. A tube can be inserted into the chest to drain the excess air.
- If the nerves near the windpipe are accidentally damaged you may have trouble speaking or swallowing.
- In rare cases the windpipe can collapse in on itself, usually because the tracheostomy has been carried out incorrectly. Further surgery will fix the problem.
- If the airways have become narrowed then the patient may still have breathing difficulties. A stent may then be used to keep the airways open.
Photograph provided by kind permission of Alin S.