Overview of Tracheostomy
A tracheostomy is a surgical procedure that involves creating an opening in the trachea, or windpipe, to help with breathing. This procedure has been performed for thousands of years, dating back to 3600 B.C. in ancient Egypt.
Back in the day, a tracheostomy was the only way to deal with blockages in the upper airway. While it’s still used for this purpose today, it’s also performed for several other reasons.
For instance, someone might need a tracheostomy in an emergency to get around a blocked airway. Most often, though, a tracheostomy is performed as a planned procedure. It can help people breathe easier if they’re on a ventilator, assist with weaning off a ventilator, or help with managing secretions in the lung, among other things.
In the past, a tracheostomy was traditionally done as an open surgical procedure in the operating room. But in recent times, more convenient methods have been developed. These newer methods, referred to as percutaneous tracheostomy techniques, can be done at the patient’s bedside and are just as safe and reliable as the traditional method.
Anatomy and Physiology of Tracheostomy
The trachea, often referred to as the windpipe, is a structure in your throat made up of incomplete rings of cartilage. These rings provide structure but necessary flexibility for your throat. The only exception is the first ring, which is complete and connects your trachea to your larynx (or voice box). This particular ring is known as the cricoid cartilage. The trachea travels down your throat, starting from just below your larynx and ending at your bronchi, the tubes that lead to your lungs. On its rear side, the trachea shares a wall with the esophagus, which is the tube that leads from your throat to your stomach.
Your trachea is covered by two muscles (the sternohyoid and sternothyroid), and is typically located just underneath the thyroid gland, which is in your neck. There are also important structures next to the trachea, such as the recurrent laryngeal nerves and some fatty tissue. These are all surrounded by a protective layer of connective tissue. On each side of the trachea, we find the common carotid arteries, which supply blood to the brain and neck. They’re encased by another layer of the protective tissue, keeping them safe and secure. As the trachea extends down, it’s positioned behind the heart and is covered by the thymus and other structures of the chest.
In terms of important landmarks for a procedure like a tracheostomy (which is a surgery to create an opening in the neck leading to the trachea), there are several key locations. You have the thyroid notch, which is a noticeable spot that signals the upper part of the larynx in the center of your neck. There is also the cricothyroid membrane, which is the place in between the cricoid and thyroid cartilages. If an emergency airway is needed, this is typically where it would be created. The cricoid cartilage helps identify where the larynx and trachea connect and is usually where a skin incision is made for a tracheostomy. Lastly, the sternal notch helps identify the location of the entrance to the chest cavity. Noting this location is important to see if there is a high-riding artery coming from the heart, which can be encountered during a tracheostomy.
Why do People Need Tracheostomy
A tracheostomy is a surgical procedure that involves placing a tube into the trachea (windpipe) to assist with breathing. It can be done either as an emergency or as a planned operation.
In an emergency, tracheostomy might be needed for issues like:
* An obstruction in the upper airway that makes it difficult to insert a breathing tube through the mouth, such as a foreign object, swelling due to infection or an allergic reaction.
* If an emergency airway has been created through the neck (cricothyrotomy), it should be converted into a formal tracheostomy to establish a secure breathing path.
* In the case of a severe facial injury that affects the creation of using an oral airway.
* After penetrating injury to the voice box area.
Generally, there are other methods to manage breathing which are less invasive and can be tried first for such situation. However, the tools for an emergency tracheostomy should be fully prepped and ready before handling the airway in these situations.
Another category of tracheostomy is planned or elective tracheostomy performed under non-emergency conditions. This might be necessary for:
* Dependency on a ventilator machine for a prolonged period.
* In preparation for treatment of head and neck cancers.
* Persistent obstructive sleep apnea not responding to other treatments.
* Recurrent inhaling of food or fluid into the lungs (aspiration).
* Certain neuromuscular diseases that make independent breathing difficult.
* Narrowing of the tube-like structure below the voice box (subglottic stenosis).
There has been a lot of debate about the timing of a tracheostomy for patients needing long-term ventilator support. Traditionally, it’s done 5 to 7 days after inserting a breathing tube through the mouth, to minimize the risk of long-term complications. However, some now say this period can be extended if there’s a good chance the person can be taken off the ventilator soon.
On the other hand, an early tracheostomy can be beneficial as it might increase patient comfort, reduce sedative needs, and decrease the time spent in the ICU or on the ventilator. This is particularly suggested in patients with severe brain injuries or difficulties in weaning off the ventilator.
A tracheostomy may also be carried out as a preventive measure before treatment for extensive injuries or large tumors in the head and neck region. Swelling resulting from the surgery or radiation therapy might lead to obstruction of the upper airway, so it’s best to have a tracheostomy done before starting treatment.
In cases of serious obstructive sleep apnea that doesn’t respond to continuous positive airway pressure, especially in significantly overweight individuals, a tracheostomy might be beneficial. Patients with long-term neurological conditions who can’t manage their saliva might need a tracheostomy to help prevent recurrent aspiration. Lastly, those with neuromuscular conditions that affect their strength to breathe, such as amyotrophic lateral sclerosis, might need a tracheostomy to assist with breathing by way of a ventilator.
When a Person Should Avoid Tracheostomy
The only real reason not to perform a tracheostomy, which is a medical procedure to create an opening in the neck to allow air to enter the lungs, is if there is an ongoing infection of the skin on the front of the neck, known as cellulitis. For patients who are facing the end of their life, it’s important to have conversations about what they want at this stage. We should clarify what their ongoing care aims are before going ahead with a tracheostomy or any other serious procedure.
Equipment used for Tracheostomy
In the operating room, a few specific tools are needed for a procedure known as a tracheostomy. Among these are what’s called a tracheostomy tray, which is a special set of tools used specifically for this type of surgery. Also, the medical team will wear personal protective equipment to both protect themselves and maintain a clean environment.
In some cases, a procedure called a percutaneous tracheostomy is performed. This specific procedure requires an additional piece of equipment, known as a bronchoscope. A bronchoscope is a tool with a camera that allows doctors to clearly see the inside of a person’s airways.
There are scenarios where tracheostomy can be challenging. In such difficult cases, doctors may use fiberoptic laryngoscopy or bronchoscopy. Laryngoscopy is a procedure that lets your doctor examine the back of your throat, including your voice box (larynx), while bronchoscopy is a procedure which allows your doctor to look at your airway through a thin viewing instrument called a bronchoscope. These tools with cameras help doctors to better understand the situation and provide safe and effective treatment.
Who is needed to perform Tracheostomy?
In an open tracheostomy procedure, that usually takes place in an operating room, a team of doctors – the main surgeon, their helper known as the surgical assistant, a nurse and a scrub tech who makes sure the medical instruments are clean and in order, are present. They also need an anesthesiologist, a doctor who is specially trained to give you medicine that puts you to sleep or blocks pain.
For a percutaneous tracheostomy, a different kind of tracheostomy that can be done either in an operating room or right next to your bed, two doctors are needed. One doctor carries out the actual procedure at your neck, while the other uses a special instrument called a bronchoscope to make sure they can see where the tube is being placed in your windpipe or trachea. This type of tracheostomy can also be done by a doctor who specializes in lung diseases, known as a pulmonologist, or a doctor who cares for patients in the intensive care unit, known as a critical care physician.
Preparing for Tracheostomy
A tracheostomy, which is a procedure to create an opening in the neck to allow air to enter the lungs, is typically performed by a surgeon in the operating room, with a supporting medical team. Often, the patient is put under general anesthesia, which means they are completely unconscious during the procedure. However, in special cases like Ludwig angina (a type of severe mouth infection), a local anesthetic can be used – this numbs only the specific area being operated on, and the patient remains awake. Initially, a cuffed, non-fenestrated tracheostomy tube is used, which is a special tube that helps keep the new airway open.
If there is a risk that the patient’s respiratory secretions (mucus or saliva from the lungs and mouth) could become airborne, the medical team should wear specialized protective gear. In addition, the procedure should be performed in a negative pressure room. This type of room prevents air from flowing out into other areas, which can reduce the spread of these secretions and help prevent others from getting sick.
How is Tracheostomy performed
Tracheostomy is a surgical procedure where a hole is made into the windpipe (trachea), through the neck to help someone breathe. There are two ways this can be done: open tracheostomy and percutaneous tracheostomy.
Open Tracheostomy
The surgery starts by identifying prominent structures on the neck such as the thyroid notch, cricoid cartilage, and sternal notch. These are felt and marked by the surgeon, who also pays attention to the sternal notch to ensure there isn’t a major artery located too high.
The surgeon then makes a skin cut in the midline of the neck, approximately 1 to 2 cm below the cricoid cartilage. This can be done either horizontally or vertically.
After the cut is made, the surgeon extends it through a neck muscle (platysma) to expose other underlying muscles (sternohyoid and sternothyroid) and the thyroid gland. If the thyroid gland is found over the trachea, it may be tied off (ligation) for temporary control of its blood supply and moved out of the way.
Once the trachea is visible, the surgeon places a hook-shaped instrument under the cricoid cartilage to lift the trachea into the surgical field. The second and third rings (segments) of the trachea are identified, and an incision (cut) is made between these rings where the tracheostomy tube will be placed.
Once the tube is positioned, it’s connected to the anesthesia machine to check the patient’s breath carbon dioxide levels. As soon as everything is in order, the hook is released, and the tube is secured with a soft tie around the neck and stitched to the neck skin until it’s changed on the fifth day after surgery.
Percutaneous Tracheostomy
In this method, which was first described in 1985, a needle and thread are inserted into the trachea in a series of steps under the guidance of a bronchoscope (small camera used to view the airways). As with open tracheostomy, the exact spot of insertion is carefully identified.
This method is usually done at the patient’s bedside, hence no need for transportation to the operating room. It tends to involve less bleeding and lower chances of infection compared to open tracheostomy. However, it has also been reported to occasionally cause serious complications such as injury to the trachea, a major artery or the esophagus, which are extremely rare with the open technique.
Your doctor will decide the suitable method for you based on your specific circumstances.
Possible Complications of Tracheostomy
Problems sometimes happen after a tracheostomy (surgery where a hole is created through the neck into the windpipe). These problems are usually categorized into those happening during the operation, right after the surgery, and later on.
During the Operation
The most common problem during a tracheostomy operation is bleeding. If the patient’s blood is not clotting as it should, which often happens in people who are extremely sick, doctors might correct this before surgery. If the patient doesn’t have enough platelets (blood cells that help stop bleeding), they might need a transfusion before the surgery can start.
Sometimes, veins and arteries in the throat might need to be moved or cut, which could potentially lead to more bleeding. Great care is necessary during these steps.
A very rare but serious problem is when a fire occurs because of the mixture of oxygen and electricity from medical tools. To prevent this, there needs to be good communication between the surgical team and anesthetic team. If a fire does happen, equipment would be removed from the patient, and then an evaluation for injury to the throat, windpipe, and esophagus would be done.
Puncturing the lungs is another rare but serious issue. This can be caused by placing the tracheostomy tube (the tube inserted through the hole in the neck into the windpipe) in the wrong place, or injuring the top of the lung. A chest X-ray can help detect this problem.
Soon After the Operation
Infection is a rare complication that can happen after this surgery. Most infections can be treated with careful cleaning of the wound, though some severe infections might need antibiotics.
In the period shortly after the operation, the tracheostomy tube can be blocked by blood or mucus. There are standard procedures in place, like regularly cleaning out the tube and using moist oxygen, that minimize the chance of this happening. The tracheostomy tube can also become dislodged or obstructed, which would require that it be repositioned or replaced.
Later After the Operation
Sometimes, the cuff of the tracheostomy tube (the inflatable part that helps secure the tube) can cause tissue damage if it’s inflated too much. This can lead to scarring and narrowing of the windpipe.
When the tracheostomy tube is removed, the hole in the neck will usually close on its own within a day or two. However, sometimes tissue might build up at the site and cause problems, which can typically be treated with a topical solution. In rare cases, a surgical procedure might be needed to fully close the hole.
A rare complication is the development of a hole between the windpipe and the esophagus (the tube that food travels down from your mouth to your stomach). This can result from too much pressure from the tube, or by having both a nasal feeding tube and a tracheostomy tube at the same time.
Another very rare but serious issue is a hole forming between the windpipe and the innominate artery (a blood vessel in the chest). This risk is higher if the tracheostomy is placed too low or the tube is too big, resulting in too much pressure on the front of the windpipe. This problem can be fatal, so it’s important that it’s caught and treated as soon as possible.
What Else Should I Know About Tracheostomy?
A tracheostomy is a surgical procedure that creates an opening in the neck leading directly to the windpipe (trachea). This alternative airway allows for long-term use of a machine (ventilator) to assist with breathing, as well as helping those who can’t clear lung secretions on their own.
The decision to have a tracheostomy should not be taken lightly. It’s important for the patient, or their caregivers, to discuss their quality of life and expectations with their doctor beforehand. This is particularly crucial if the patient is elderly or terminally ill.
However, it’s important to keep in mind that a tracheostomy can lead to a high amount of respiratory particles (tiny droplets or solids suspended in the air) being released. This is particularly concerning when the patient has an infectious disease that can be spread through the air, like tuberculosis or COVID-19. Special measures need to be taken during these types of procedures to protect the medical staff in the operating room.
