Tracheostomy

General Information about Tracheostomy
Tracheostomy (Tray-kee-AH-stuh-mee) is a surgical opening in the trachea (windpipe) that forms a temporary or permanent opening to make breathing easier.

The terms "tracheotomy" and "tracheostomy" are used interchangeably
The opening is called a stoma.

A tracheotomy tube is inserted in the opening to keep it open.

Emergency tracheostomy is performed as a lifesaving procedure
History:

Tracheostomy in early days was considered slashing of the neck to save a life.

Even though tracheostomy procedure existed right from the Rig Vedas it was

In 1718 that Lorenz Heister coined the term tracheotomy

In 1921 Chevalier Jackson described the indications and techniques for modern tracheostomy.

Tracheostomy - Anatomy
The trachea is also called windpipe

The trachea and esophagus run parallel to each other through the chest cavity.

The esophagus is connected to the stomach, and helps in carrying food and saliva to the stomach.

The trachea, which is connected to the lungs, carries air to the bronchi and the lungs.

As we breathe the air passes through the throat into the trachea (windpipe).

The trachea is then divided into the left and right bronchi.

Each bronchus divides again and again like a branch of a tree, becoming narrower and narrower.

Tracheostomy Indications
Now a days tracheostomy is done only in those cases in which intubation by a mouth or nasal tube is not a feasible option.

There are broadly four groups of patients on whom tracheostomy needs to be performed:

1. To relieve breathing difficulties by any blockage in the airway passages for example-

  · Foreign body Impactation in the airways.
  · Acute infection of the airways
  · Edema of the airways
  · Paralysis of vocal cords following injury
  · Tumors of the vocal cords
  · Trauma in the region

2. To improve respiratory functions by reducing the length of the airway, which may be required in special lung conditions like- Bronchopneumonia

  · Bronchitis with Emphysema
  · Chest injury
In these conditions the tracheostomy tube also helps in aspiration of excessive secretion that may be caused due to infection or injury

3. Respiratory nerve damage temporary or permanent causing paralysis of chest muscles that assist in breathing. In these situations performing assisted or positive pressure respirations may be required in conditions like-

  · Unconsciousness associated with head injuries
  · Barbiturate poisoning
  · Poliomyelitis
  · Tetanus
These patients may also aspirate their gastric content into the lungs and a  tracheostomy tube may be helpful for aspiration these secretions.

4. As a preliminary step in certain surgeries on the upper airway.

Advantages of Tracheostomy

Tracheostomy has certain advantageous over the temporary tube called endotracheal tube because it-

  . Reduces patient discomfort
  · Reduces need for sedation
  · Improves ability to maintain oral and bronchial hygiene
  · Reduces risk of trauma to the windpipe and trachea
  · Makes breathing easier with less effort for a sick patient
  · Easier to move off assisted breathing using a ventilator.

Tracheostomy - Procedure
The patient is made to lie down on their back with the neck & head extended by keeping a pillow under the shoulder and neck.

Local anaesthesia or general anaesthesia is used for the procedure.

A horizontal cut is made across the neck above the 'sternal notch' using a knife.

The skin is separated and surrounding tissues are dissected to expose the trachea.

The 2nd or 3rd of the tracheal ring is incised for the tracheostomy tube to be placed.

A suitable size tracheostomy tube is then introduced inside. While choosing the tube, the smallest feasible tube should be used. A general rule is that the tube should be three fourths of the diameter of the trachea.

The cuff of the tube is inflated by using 2-5 ml of air and it is held in place by using a necktie.

The incision is closed using skin sutures by the side of the tracheostomy tube.

Dressing is applied for the wound to heal.

Tracheostomy- Post Operative Care
The tube, called a "trach" (trayk) for short, has three parts. 


The "Obturator" that is used to pass the trach into the windpipe.
    An "Outer cannula" (tube). This Outer cannula has a plastic "trach plate" that lies against the skin on the neck and holds the trach in place.

And an "Inner cannula" that fits inside the outer one and locks into place.

Many of the patients need 1 to 3 days time to adapt themselves to breath through the tracheostomy tube.

Painkillers and antibiotics are given as per the patients need.

The patient will have to try and make adjustments to communicate. It would be very difficult for the patient to initially make any noise or sounds let alone trying to speak.

Most patients can learn to speak with a tracheostomy tube after much training and practice.

Once the underlying problem that caused the tracheostomy tube to be placed in the first place in healed then the tube would be removed.

A small scar would remain with the hole healing quickly.

Long term care for tracheostomy tube

Patients or attenders should learn how to take care of the tracheostomy if they are to be discharged home after the procedure. This will help them to take care of the tube at home.

Normal lifestyles are encouraged and most activities can be resumed.

  Some tubes have an inflatable cuff near the outer end to keep them from coming out and to prevent air from leaking around them.

As long as the tracheostomy tube is in place, the inner cannula should be cleaned on a daily basis.

Whenever the tube seems like becoming clogged with mucus, it will have to be cleared by suction.

The procedures are important as a dirty cannula could lead to infection. and if the trach clogs up, the patient will be unable to breath.

Cleaning and suctioning of the tracheostomy tube must be followed strictly and is perhaps one of the most important instructions given at the time of discharge.

Complications of Tracheostomy
Common complications with tracheostomy are-

Wound infections

Air leakage

Improper air entry

Tracheal ring narrowing or Stenosis (usually with high tracheostomy)

Ulceration of the trachea or main bronchi

Entrapment of air under the skin (called surgical emphysema), this is a self-limiting condition that resolves spontaneously.

Tracheostomy - Faqs
Which doctor performs tracheostomy? 
An ENT specialist surgeon is the doctor who performs tracheostomy.

How painful was the surgery? 
There is very little pain immediately after the surgery that could be compared to a moderate headache.

  What kind of anaesthesia do they use for the surgery?
The trach surgery is generally done under local anaesthesia but sometimes it is done under general anaesthesia. 

How long does it take to heal? 
It depends on the reason for which the procedure is being undertaken. If it were for simple obstruction or simple causes like 'sleep apnoea' then it generally would heal in about 7 days after the surgery. 

What do you have to do to care for the tracheostomy tube? 
After the surgery the area around tube has to be cleaned with gauze dipped in hydrogen peroxide. The tube would have to be suctioned whenever it becomes clogged.

Why is suctioning of a tracheostomy tube needed?
Having a tracheostomy tube increases the production of mucus in a patient and a decreases their ability to be able to cough out the mucus. Hence suctioning helps in getting rid of the blockage and marinating the proper airflow.

How do we know if someone we are caring for needs to be suctioned?
The person usually communicates, but in people who don't and in infants there are a number of signs one can look for that may indicate the need to be suctioned.

 Noisy breathing (a rattling or the sound of mucus bubbling)
 Rate of breathing increases
The person appears uncomfortable, fussy, agitated or restless
Inadequate chest movement upon inhalation
Nasal flaring
Infant has difficulty sucking
Mucus can be seen bubbling at the tube opening
Non-productive cough
Blue colour around the lips, mouth or fingernails (cyanosis)

Can a suit with a tie be worn during the day? 
No ties should be worn as the tube could get pushed back in.

Does the voice change in terms of clarity or loudness? 
The voice usually does not change.

Tracheostomy - Glossary
Trachea: The airway that leads from the larynx to the lungs. Also called the windpipe.

Esophagus: The muscular tube through which food passes from the throat to the stomach.

Stomach: A muscular pouch that helps in the digestion of food by mixing it with digestive juices and churning it into a thin liquid.

Saliva: The watery fluid secreted into the mouth by the salivary glands that are in the mouth. It keeps the mouth moist, lubricates food to aid in swallowing, makes it possible to taste food, and contains digestive enzyme (a protein that begins the breakdown of food).

Bronchi: The large air passages that lead from the trachea (windpipe) to the lungs.

Lungs: The two organs of respiration that bring air and blood into close contact so that oxygen can be added to and carbon dioxide removed from the blood.

Infection: Invasion of the body by agents (bacteria, viruses or fungi) that cause disease or tissue damage.

Edema: Swelling caused by excess fluid in body tissues.

Paralysis: Complete or partial inability to move a part of the body.

Vocal cords: Two small bands of muscle within the larynx that vibrate to produce the voice.

Tumor: A location where cells in the body multiply at an increased rate. Some tumors are benign (not cancerous), others are malignant (cancerous).

Trauma: The process or event leading to an injury or wound.

Pneumonia: An inflammatory infection that occurs in the lung.

Bronchitis: Inflammation (swelling and reddening) of the bronchi.

Emphysema: Emphysema is a disorder affecting the alveoli (tiny air sacs) of the lungs. The transfer of oxygen and carbon dioxide in the lungs takes place in the walls of the alveoli. In emphysema, the alveoli become abnormally inflated, damaging their walls and making it harder to breathe.

Barbiturate: A drug with sedative and hypnotic effects. Barbiturates have been used as sedatives and anaesthetics, and they have been used to treat the convulsions associated with epilepsy.

Tetanus: A serious disease affecting the central nervous system. Tetanus (lockjaw) results when a wound is infected with a type of bacteria that thrives without oxygen (particularly in deep wounds).

Aspiration: Removal of fluid by suction from cavities such as nose, throat, from a lump, often a cyst, with a needle and a syringe Vomit: The ejection of contents of the stomach through the mouth; or, the material itself.

Glottis: The middle part of the larynx; the area where the vocal cords are located.

Anaesthesia: Loss of feeling or sensation resulting from the administration of certain drugs or gases.

Incision: A cut made in the body during surgery.

Sternal notch: A notch made by the breastbone.

Scalpel: An instrument used in surgery for making incision.

Scar: A mark left on damaged tissue after it has healed.

Mucus: A thick, slippery fluid produced by the membranes that line certain organs of the body, including the nose, mouth, throat, and vagina.

Stenosis: The narrowing or closure of an opening or passageway in the body.

Tracheostomy - Reference
Bailey & Love's Short Practise Of Surgery- 21st ELBS Edition
  • Revised By Charles V. Mann & R.C.G.Russel
    Manipal Manual Of Surgery-Millennium, CBS, Edition
  • K.Rajgopal Shenoy





Online
  • www.henryfordhealth.org/
    18832.cfm
  • www.shands.org/health/
    surgeries/100103.html
  • www.adam.about.com/surgery/
    100103.htm
  • www.lung.ca/lung101-renseignez/
    respiratory-respiratoire/how-comment
    /index_e.php
  • www.wakemed.com/16853.cfm

Submitted By: Dr.Vivek



Edited By:   Dr.Shroff
                  Dr.Ramya

    

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