Tracheotomy

Definition

A tracheotomy is a surgical procedure that opens up the windpipe (trachea). It is performed in emergency situations, in the operating room , or at bedside of critically ill patients. The term tracheostomy is sometimes used interchangeably with tracheotomy. Strictly speaking, however, tracheostomy usually refers to the opening itself while a tracheotomy is the actual operation.

Purpose

A tracheotomy is performed if enough air is not getting to the lungs, if the person cannot breathe without help, or is having problems with mucus and other secretions getting into the windpipe because of difficulty swallowing. There are many reasons why air cannot get to the lungs. The windpipe may be blocked by a swelling; by a severe injury to the neck, nose, or mouth; by a large foreign object; by paralysis of the throat muscles; or by a tumor. The patient may be in a coma, or need a ventilator to pump air into the lungs for a long period of time.

Demographics

Emergency tracheotomies are performed as needed in any person requiring one.

Description

Emergency tracheotomy

There are two different procedures that are called tracheotomies. The first is done only in emergency situations and can be performed quite rapidly. The emergency room physician or surgeon makes a cut in a thin part of the voice box (larynx) called the cricothyroid membrane. A tube is inserted and connected to an oxygen bag. This emergency procedure is sometimes called a cricothyroidotomy .

Surgical tracheotomy

The second type of tracheotomy takes more time and is usually done in an operating room. The surgeon first makes a cut (incision) in the skin of the neck that lies over the trachea. This incision is in the lower part of the neck between the Adam's apple and top of the breastbone. The neck muscles are separated and the thyroid gland, which overlies the trachea, is usually cut down the middle. The surgeon identifies the rings of cartilage that make up the trachea and cuts into the tough walls. A metal or plastic tube, called a tracheotomy tube, is inserted through the opening. This tube acts like a windpipe and allows the person to breathe. Oxygen or a mechanical ventilator may be hooked up to the tube to bring oxygen to the lungs. A dressing is placed around the opening. Tape or stitches (sutures) are used to hold the tube in place.

After a nonemergency tracheotomy, the patient usually stays in the hospital for three to five days, unless there is a complicating condition. It takes about two weeks to recover fully from the surgery.

Diagnosis/Preparation

Emergency tracheotomy

In the emergency tracheotomy, there is no time to explain the procedure or the need for it to the patient. The patient is placed on his or her back with face upward (supine), with a rolled-up towel between the shoulders. This positioning of the patient makes it easier for the doctor to feel and see the structures in the throat. A local anesthetic is injected across the cricothyroid membrane.

Nonemergency tracheotomy

In a nonemergency tracheotomy, there is time for the doctor to discuss the surgery with the patient, to explain what will happen and why it is needed. The patient

For a tracheotomy, an incision is made in the skin just above the sternal notch (A). Just below the thyroid, the membrane covering the trachea is divided (B), and the trachea itself is cut (C). A cross incision is made to enlarge the opening (D), and a tracheostomy tube may be put in place (E). (

Illustration by GGS Inc.

)

Aftercare

Postoperative care

A chest x ray is often taken, especially in children, to check whether the tube has become displaced or if complications have occurred. The doctor may prescribe antibiotics to reduce the risk of infection. If the patient can breathe without a ventilator, the room is humidified; otherwise, if the tracheotomy tube is to remain in place, the air entering the tube from a ventilator is humidified. During the hospital stay, the patient and his or her family members will learn how to care for the tracheotomy tube, including suctioning and clearing it. Secretions are removed by passing a smaller tube (catheter) into the tracheotomy tube.

It takes most patients several days to adjust to breathing through the tracheotomy tube. At first, it will be hard even to make sounds. If the tube allows some air to escape and pass over the vocal cords, then the patient may be able to speak by holding a finger over the tube. Special tracheostomy tubes are also available that facilitate speech.

The tube will be removed if the tracheotomy is temporary. Then the wound will heal quickly and only a small scar may remain. If the tracheotomy is permanent, the hole stays open and, if it is no longer needed, it will be surgically closed.

Home care

After the patient is discharged, he or she will need help at home to manage the tracheotomy tube. Warm compresses can be used to relieve pain at the incision site. The patient is advised to keep the area dry. It is recommended that the patient wear a loose scarf over the opening when going outside. He or she should also avoid contact with water, food particles, and powdery substances that could enter the opening and cause serious breathing problems. The doctor may prescribe pain medication and antibiotics to minimize the risk of infections. If the tube is to be kept in place permanently, the patient can be referred to a speech therapist in order to learn to speak with the tube in place. The tracheotomy tube may be replaced four to 10 days after surgery.

Patients are encouraged to go about most of their normal activities once they leave the hospital. Vigorous activity is restricted for about six weeks. If the tracheotomy is permanent, further surgery may be needed to widen the opening, which narrows with time.

Risks

Immediate risks

There are several short-term risks associated with tracheotomies. Severe bleeding is one possible complication. The voice box or esophagus may be damaged during surgery. Air may become trapped in the surrounding tissues or the lung may collapse. The tracheotomy tube can be blocked by blood clots, mucus, or the pressure of the airway walls. Blockages can be prevented by suctioning, humidifying the air, and selecting the appropriate tracheotomy tube. Serious infections are rare.

Long-term risks

Over time, other complications may develop following a tracheotomy. The windpipe itself may become damaged for a number of reasons, including pressure from the tube, infectious bacteria that forms scar tissue, or friction from a tube that moves too much. Sometimes the opening does not close on its own after the tube is removed. This risk is higher in tracheotomies with tubes remaining in place for 16 weeks or longer. In these cases, the wound is surgically closed. Increased secretions may occur in patients with tracheostomies, which require more frequent suctioning.

High-risk groups

The risks associated with tracheotomies are higher in the following groups of patients:

• children, especially newborns and infants
• smokers
• alcoholics
• obese adults
• persons over 60
• persons with chronic diseases or respiratory infections
• persons taking muscle relaxants , sleeping medications, tranquilizers, or cortisone

Normal results

Normal results include uncomplicated healing of the incision and successful maintenance of long-term tube placement.

Morbidity and mortality rates

The overall risk of death from a tracheotomy is less than 5%.

Alternatives

For most patients, there is no alternative to emergency tracheotomy. Some patients with pre-existing neuromuscular disease (such as ALS or muscular dystrophy) can be sucessfully managed with emergency noninvasive ventilation via a face mask, rather than with tracheotomy. Patients who receive nonemergency tracheotomy in preparation for mechanical ventilation may often be managed instead with noninvasive ventilation, with proper planning and education on the part of the patient, caregiver, and medical staff.

Resources

BOOKS

Bach, John R. Noninvasive Mechanical Ventilation. NJ: Hanley and Belfus, 2002.

Fagan, Johannes J., et al. Tracheotomy. Alexandria, VA: American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc., 1997.

"Neck Surgery." In The Surgery Book: An Illustrated Guide to 73 of the Most Common Operations , ed. Robert M. Younson, et al. New York: St. Martin's Press, 1993.

Schantz, Nancy V. "Emergency Cricothyroidotomy and Tracheostomy." In Procedures for the Primary Care Physician , ed. John Pfenninger and Grant Fowler. New York: Mosby, 1994.

OTHER

"Answers to Common Otolaryngology Health Care Questions." Department of Otolaryngology–Head and Neck Surgery Page. University of Washington School of Medicine [cited July 1, 2003]. http://weber.u.washington.edu/~otoweb/trach.html .

Sicard, Michael W. "Complications of Tracheotomy." The Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences. December 1, 1994 [cited July 1, 2003]. http://http:www.bcm.tmc.edu/oto/grand/12194.html .

Jeanine Barone, Physiologist Richard Robinson

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Tracheotomy is performed by a surgeon in a hospital.

QUESTIONS TO ASK THE DOCTOR

• How do I take care of my trachesotomy?
• How many of your patients use noninvasive ventilation?
• Am I a candidate for noninvasive ventilation?