Ask a Doctor: Tracheostomy

Introducing: Ask a Doctor

At UTHSC ENT, we understand that patients need clear, helpful answers to their questions. We also know that a flood of new information can be overwhelming.

That’s why our department’s introducing Ask a Doctor: an ongoing series of posts that tackle Frequently Asked Questions about common issues. We hope these articles give you a better understanding of your situation and an easy path to treatment.

Today, we discuss a well-known and complicated treatment: tracheostomy.

Prepared by: Kaes Pepke
Reviewed by: Dr. Sandra Stinnett

What is a tracheostomy?

In a recent profile, we shared Dr. Sheyn’s experience finding an alternative treatment to a tracheostomy for a pediatric patient.

But what is a tracheostomy? And what are its benefits and considerations?

A tracheostomy is a small hole surgically created in the front of the neck leading into the trachea (more commonly known as the windpipe). The surgery by which this hole is created is termed a tracheotomy and involves the placement of a small tube known as a tracheostomy tube.

Placement of this tube allows for breathing which bypasses the normal route. This may be necessary due to blockage or impaired function in the normal path of breathing.

In many cases this procedure may be reversible when the tracheostomy is no longer needed but may also be permanent in some cases. Emergency tracheostomies may be needed should the airway become suddenly blocked or injured.

What is an emergency tracheostomy?

Emergency tracheostomies often are performed outside of hospitals due to sudden obstruction or damage of an airway. These procedures are typically performed at the site of an accident when time is an important survival factor.

Emergency tracheostomies carry significantly more risks than hospitalized and planned tracheostomies.

Why is it performed?

Tracheostomies may be performed for a variety of reasons, including:

• Emergency placement due to obstructed breathing, often resulting from inability to place a breathing tube through the mouth.
• When a ventilator is in use for extended periods, typically greater than 2 weeks. This is usually due to a medical condition.
• Illnesses or conditions that may block normal breathing such as throat cancer, infection, or swollen tongue. These conditions often cause inadequate air to the lungs.
• Prior to a surgery where normal breathing may be obstructed. These tracheostomies are often temporary.
• Paralysis or coma where direct clearance of the windpipe may be necessary due to inability of the patient to breathe on their own.
• A variety of other causes, both emergent and non-emergent, in which breathing is obstructed or weakened.

What are the risks?

Non-emergent tracheostomies are considered relatively safe procedures. However, there are a number of risks associated with the procedure and time period following the procedure. Emergency tracheostomies are associated with a higher level of risk and increased likelihood of complications.

Complications include, but are not limited to:

• Bleeding
• Trapping of air surrounding the lungs (pneumothorax), deep layers of the chest (pneumomediastinum), or skin surrounding tracheostomy (subcutaneous emphysema)
• Displacement or damage to tracheostomy tube
• Pooling of blood (hematoma) in the neck or chest which may cause breathing difficulty
• Breathing pain or lung collapse, often due to pneumothorax
• Injury to surrounding nerves, thyroid gland, or the trachea

Long-term complications typically increase with length of time the tracheostomy tube is kept in place. They include:

• Accidental removal or obstruction of the tracheostomy tube
• Infection around tracheostomy tube, the trachea (tracheobronchitis), or the lungs (pneumonia)
• Damage to the trachea causing scarring or narrowing (may require additional procedures)
• Development of a passage from the windpipe (trachea) to the esophagus termed a tracheoesophageal fistula
• Development of a passage from the windpipe (trachea) to the arteries of the right arm, head, and neck which may result in life threatening bleeding (tracheoinnominate fistula)

What happens during the procedure?

Typically, tracheostomies are performed under either general anesthesia or with the use of a local anesthetic.

Local anesthetics are usually used in situations in which general anesthesia is not an option or has increased risk. Tracheotomies are usually either surgical or minimally invasive (percutaneous).

These entail the following:

1) Surgical tracheostomy
A horizontal incision is made on the front of the neck, exposing surrounding muscles and a small portion of thyroid gland. The muscles are retracted, and the thyroid gland cut to view the windpipe (trachea). A small hole will be placed in the windpipe to allow for passage of the tube. A neck strap is attached to the tube in order to prevent displacement; this may require sutures.

2) Percutaneous tracheostomy
A small incision is made in the front of the neck toward the base. A small camera is placed in the throat through the mouth to allow for the surgeon to view the inside of the throat. A needle is then guided through the small incision using the camera view. The hole created by the needle is then expanded to create an opening for placement of the tube. A neck strap is attached to the tube in order to prevent displacement; this may require sutures.

What should I expect following the procedure?

Following the procedure, you will likely need to spend a few days in the hospital to heal under supervision, during which specific instructions will be provided on caring for your tracheostomy tube.

However, here are some things to expect post-operatively:

Speech Impairment:
Due to the placement of the tube, air will no longer exit through the mouth and vocal cords, leading to the inability to properly speak. Speech may be retained depending on tube type and placement. Some devices may be needed to attain speech, or in some cases speech therapy may be helpful.

Eating and Drinking:
Following the procedure, you may experience difficulty swallowing, making it difficult to eat or drink. To overcome this, nutrients may be provided intravenously (IV line into a vein), through a feeding tube through the mouth or nose, or with a direct tube to tube the stomach. Therapy to strengthen the muscles of swallowing and regain coordination may be needed.

Irritation and Coughing:
Placement of the tracheostomy tube bypasses the nose and mouth which moisten air. This may cause drier air which can lead to mucous drainage into the tracheostomy tube. It may also cause irritation and coughing. Following hospital recommendations, a small amount of saline solution inserted into the tube may help with these effects. Humidifiers may also be helpful in moistening the air which you breathe. Other devices, such as saline nebulizers, may be beneficial in relieving symptoms.

How can our Dream Team help?

UTHSC ENT’s Dream Team provides world class treatment in your hometown. Our tracheostomy profiles demonstrate what sets us apart: individualized treatment for every patient.

If you have any issue with your airway, we’d love to hear from you!