Tracheostomy

Anatomy and Physiology

The trachea, or windpipe as it is known colloquially, is a circular tube that allows air you breathe to enter into your lungs. The trachea starts at your voice box in the upper part of the neck down into the chest. The trachea is a circular tube made up of 16-20 rings of cartilage. A tracheostomy is a surgically created opening into the trachea. A tracheostomy tube is inserted into that hole and allows a direct passage of air from the environment or from a breathing machine called a ventilator, into the lungs.

Who is at risk?

A tracheostomy may be performed to fix a variety of problems including:

• Decreased air flow into the lungs caused by an inherited abnormality of the larynx or trachea
• Compression of the trachea caused by swelling or bleeding brought on by severe neck or mouth injuries
• Damage to the trachea caused by breathing corrosive material, smoke, or steam
• A large object blocking the trachea, such as a tumor
• Excess secretions and mucous building up in the airway, of which a tracheostomy is used to facilitate clearance
• Paralysis of the muscles that affect swallowing
• Long-term unconsciousness or coma.

Patients who need prolonged breathing support from a ventilator (longer than 2 weeks) will often have this procedure performed. A tracheostomy in the neck is preferable to a breathing tube inserted through the mouth because it is often more comfortable for the patient. It can also be safer as the breathing tube through the mouth can cause damage to the trachea resulting in narrowing if placed for longer than 2 weeks. Finally, it is easier to “wean” the patient off the ventilator with a tracheostomy tube than with a breathing tube. Patients can be disconnected from the ventilator and breathe on their own through a tracheostomy tube. These breathing trials – or trach collar trials, as they are often called – are often done as “mock” trials to see how well someone can breathe on their own without the help of a ventilator. Trach collar trials can be performed for a few hours at a time. In between trials, the tracheostomy tube is reconnected to the ventilator to provide the patient with a period of rest.

How is the surgery performed?

A small horizontal or vertical 1-inch incision is made into the neck below the Adam’s apple but above the breastbone. The neck muscles are parted, and the trachea is identified. An incision is made between the tracheal rings. The tracheostomy tube is inserted through this hole between the rings down to the trachea. A supply of oxygen can be attached to the tube to increase the flow of oxygen to the lungs. The tracheostomy tube can also be attached to a ventilator if the patient is unable to breathe on his or her own.

Complications from Surgery?

This is a commonly performed and safe procedure. Risks include damage to the voice box or esophagus during the procedure or a collapsed lung. These complications tend to occur early after surgery but are very rare. Complications that tend to occur months to years after tracheostomy surgery include erosion of the tracheostomy tube into a nearby artery or to the esophagus. These complications require an operation to be fixed. Tracheostomy tubes require regular maintenance cleaning or else they can get clogged with mucous or other secretions.

What to expect after surgery?

It takes some time to adapt to breathing through a tracheostomy tube. With training and practice, most patients can learn to talk with a tracheostomy tube in place. However, when on the ventilator, a person is unable to talk.

Between 4 and 10 days after surgery, the initial tracheostomy tube will be changed to a smaller tube. Tracheostomies can be temporary or permanent. If temporary, the tracheostomy tube will be downsized to a smaller tube usually in at least two different changes. Once the tracheostomy tube is removed, a dressing is placed over the hole. The hole generally seals up on its own within a few days. In rare cases, the hole does not close and a second operation is required to close it. If the tracheostomy is meant to be permanent, home care instructions will be given prior to discharge from the hospital. Regular cleaning of the tracheostomy is required to clean the secretions that might build up.