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Tracheostomy
Creating an opening into the windpipe in the neck

Tracheostomy (sometimes called tracheotomy) is the creation of an opening directly into the trachea (windpipe) in the neck for the purpose of assisting breathing. While tracheotomy used to be done as an emergency, it is now done more on an elective basis to protect the airway, better clean the airway and to provide more oxygen to the lungs.

Anatomy and Physiology

  • At the back of the mouth and nose the air passages form the pharynx, which continues into the larynx (voice box). The larynx may be felt as the Adam's apple in front of the neck (Figures 1 and 2)
  • The trachea is a tube that runs from the bottom of the larynx into the chest where it divides into the bronchi, the tubes that go to each of the lungs
  • The thyroid gland lies in front of the trachea. The esophagus (foodpipe) lies behind it
  • The innominate artery passes in front of the lower tracheal rings of the trachea. This artery is a branch of the aorta (the major artery coming from the heart) and gives rise to the arteries to the right side of the brain and right arm
  • The trachea is a rigid structure formed from rings of cartilage to ensure that the airway always remains open. Its function is to maintain and protect the airway. The trachea is lined with mucus glands, which humidifies air as it passes through the trachea and catches small particles before they reach the lungs.
  • The trachea also has specialized hair like structures called cilia that move rhythmically to sweep mucus and particles back up to the throat. The trachea also has many defensive cells that kill organisms that enter the trachea
  • The trachea is supplied by nerves that are part of the cough reflex that helps get rid or irritants
Figure 1 - The trachea as seen from in front. The trachea lies below the thyroid cartilage, which forms the front wall of the larynx. The thyroid isthmus crosses the trachea and the recurrent laryngeal nerve (to the vocal cords) lies on each side of the trachea. © T. GravesFigure 2 - Section through the neck showing the relationships of the trachea to the larynx, esophagus and thyroid isthmus. © T. Graves

Pathology

  • Obstruction of the air passages may occur as a result of:
    1. Swallowing of a foreign material or improper swallowing of food
    2. Swelling of the air passages due to allergy
    3. Loss of trachea stiffness due to weakening of the tracheal rings, which may be either present at birth or from prolonged placement of a tube in the trachea (see Anesthesia)
    4. Injury to the face and upper airways
    5. Obstruction usually takes place in the larynx, which is the narrowest part of the air passages
  • Patients on a ventilator (breathing machine) for a long time
    1. May be sedated and may not be able to cough to clear secretions from the lung and trachea which causes plugging of the air passages
    2. May vomit and aspirate food into the lungs causing pneumonia
    3. May need increased delivery of oxygen. A tracheotomy bypasses the larynx and delivers air directly into the trachea
    4. May develop ulcers around the mouth as well as weakness and narrowing of the larynx and upper trachea from prolonged pressure of the breathing tubes that pass through the mouth
  • Cancers of the upper airway may cause obstruction that may require a tracheostomy. Surgery for cancers of the upper airway also frequently require a tracheostomy

Indications for surgery

  • Emergent indications for a tracheostomy are few. In situations of acute obstruction of the airway due to trauma or allergic swelling, an immediate airway is better obtained by intubating (inserting a tube) the trachea by mouth or nose. Sometimes it may be necessary to guide the tube into the trachea using a flexible bronchoscope (a camera on a flexible tube). If necessary, a cricothyroidectomy, which is a small incision in the lower larynx, may be made to allow air passage. These measures may be temporary until the patient is stable enough to undergo a tracheostomy in the operating room
  • A tracheostomy is advisable for patients who have been on a ventilator for over 5-7 days. A tracheostomy helps in suctioning of secretions, increased delivery of air to the lungs, prevention of aspiration in case the patient vomits and prevention of complications associated with endotracheal tubes through the mouth.
  • Patients with cancers of the upper airway undergoing surgery (see Laryngectomy) may need bypass of their airway circuit, with creation of a permanent tracheostomy.

Surgical Procedure

  • Before performing a tracheostomy the site of obstruction should be determined to be above the site of the tracheostomy. Patients with large or short necks may be difficult to operate upon
  • Bleeding disorders or an enlarged thyroid gland should be evaluated
  • The procedure is usually done under general anesthesia in the operating room. However, if the patient is sedated on a ventilator, it may be done under local anesthetic, even at the patient's bedside
  • The patient is placed supine (on the back) with the head extended to expose the front of the neck (Figure 3)
  • The incision is made over the second tracheal ring below the larynx. The incision may be made from side to side or up and down (Figure 4)
Figure 3 - The patient is placed with the head and neck extended. © T. GravesFigure 4 - The procedure can be carried out using either a vertical (up and down) or horizontal (side to side) incision. © T. Graves
  • The underlying small muscles in front of the trachea are spread to the side
  • Sometimes the isthmus (thin middle portion) of the thyroid (see Thyroidectomy) may have to be cut to expose the second tracheal ring
  • Once the trachea is exposed, an incision is made through the second and sometimes third tracheal cartilage rings. The incision may be in the form of a flap or a small segment the tracheal ring may be removed (Figure 5)
  • The tracheostomy tube, the metal or plastic tube to be placed in the trachea, is measured for size to fit the trachea
  • The anesthetist slowly withdraws the endotracheal tube through the mouth. As soon as the tube is pulled above the level of the second cartilage, the tracheostomy tube is pushed into the trachea and directed downwards. The tube contains an obturator (central portion) that has a cone shaped nose to guide the tube into the trachea. The obturator is removed after the tube is inserted (Figure 6)
Figure 5 - The trachea is exposed and an incision made in the second tracheal ring. © T. Graves Figure 6 - The tracheostomy tube is inserted into the trachea. © T. Graves
  • The tracheostomy tube has a balloon at its end, which is inflated to prevent secretions from getting into the lungs (Figure 7)
  • The tube from the breathing machine or oxygen tube is connected to the tracheostomy tube.
  • Sutures are used to close the skin incision and a cloth tape is tied around the neck to secure the tube (Figure 8)
Figure 7 - The position of the tracheostomy tube in the trachea. Note that the balloon on the tube is inflated to prevent secretions from going into the lungs. © T. Graves Figure 8 - The wound is closed around the tracheostomy tube. © T. Graves

Complications

  • Tracheostomies can become contaminated and improper care can lead to infection of the skin, trachea or lungs
  • Bleeding may occur from injury to a high innominate artery, jugular veins or thyroid gland. Severe bleeding may occur if the tracheostomy tube erodes through the anterior wall of the trachea into the arteries that lie there or into the thyroid gland. This may be a problem particularly in children where the tracheas are smaller. The bleeding may be life threatening and needs emergency surgery to control the bleeding
  • Prolonged use of a tracheostomy tube may cause stenosis (narrowing) of the trachea from scarring or tracheomalacia (floppiness of the trachea). These may cause progressive obstruction of the trachea requiring surgery to remove the scarred or weakened portion of the trachea
  • Pneumothorax (air between the lung and chest wall) may occur following tracheostomy. This occurs more frequently in children
  • Obstruction of the tube can occur from a blood clot or mucous plug and if the end of the tube presses against the back wall of the trachea
  • The tube may come out. This is a very serious complication since the patient may not be able to breath
  • Tracheoesophageal fistula (connection between the trachea and the esophagus) can occur if the tube erodes through the back of the trachea and into the esophagus. Surgery is necessary to separate the trachea and esophagus
  • Dysphagia (difficulty in swallowing) may occur from pressure of the tube on the back of the trachea
  • Poor laryngeal function may result from prolonged use of a tracheostomy

Care After Surgery

  • It is very important to keep the tracheostomy clear of secretions
  • The tracheostomy tube has a double lumen (a tube within a tube) made of plastic. The inner tube may be removed for cleaning. It is also important to suction out the tracheostomy several times a day to clear secretions
  • The air going through the tracheostomy is humidified to prevent the trachea from drying up
  • The dressing around the tracheostomy opening is changed daily and kept dry
  • As the patient recovers and does not need ventilator assistance, the patient may become apprehensive. It is not possible to talk with a tracheostomy tube in place as air is bypassed from the voice box and this may be distressing to a patient
  • Fenestrated tubes (tubes with a side-hole through them) allow air to pass through the tube into the voice box. As the patient recovers, the opening in the neck may be capped and the patient may be able to talk
  • As the patient recovers, the tracheostomy tube may be changed at the bedside into a smaller size and eventually removed. The opening in the neck closes by itself in about a week
  • Patients who have permanent tracheostomies are taught to care for their tubes. They should not to go swimming and should be careful while taking a bath to prevent water from entering the tube and causing aspiration pneumonia