Definition

A tracheotomy is a surgical procedure in which a cut or opening is made in the windpipe (trachea). The surgeon inserts a tube into the opening to bypass an obstruction, allow air to get to the lungs, or remove secretions. The term tracheostomy is sometimes used interchangeably with tracheotomy. Strictly speaking, however, tracheostomy usually refers to the opening itself while a tracheotomy is the actual operation.

Purpose

A tracheotomy is performed if enough air is not getting to the lungs, if the person cannot breathe without help, or is having problems with mucus and other secretions getting into the windpipe because of difficulty swallowing. There are many reasons why air cannot get to the lungs. The patient's windpipe may be blocked by a swelling; by a severe injury to the neck, nose or mouth; by a large foreign object; by paralysis of the throat muscles; or by a tumor. The patient may be in a coma, or need a ventilator to pump air into the lungs for a long period of time.

Precautions

Doctors perform emergency tracheotomies as last-resort procedures. They are done only if the patient's windpipe is obstructed and the situation is life-threatening.

Description

Emergency tracheotomy

There are two different procedures that are called tracheotomies. The first is done only in emergency situations and can be performed quite rapidly. The emergency room physician or surgeon makes a cut in a thin part of the voice box (larynx) called the cricothyroid membrane. A tube is inserted and connected to an oxygen bag. This emergency procedure is sometimes called a cricothyroidotomy.

Nonemergency tracheotomy

The second type of tracheotomy takes more time and is usually done in an operating room. The surgeon first makes a cut (incision) in the skin of the neck that lies over the trachea. This incision is in the lower part of the neck between the Adam's apple and top of the breastbone. The neck muscles are separated and the thyroid gland, which overlies the trachea, is usually cut down the middle. The surgeon identifies the rings of cartilage that make up the trachea and cuts into the tough walls. A metal or plastic tube, called a tracheotomy tube, is inserted through the opening. This tube acts like a windpipe and allows the person to breathe. Oxygen or a mechanical ventilator may be hooked up to the tube to bring oxygen to the lungs. A dressing is placed around the opening. Tape or stitches (sutures) are used to hold the tube in place.

After a nonemergency tracheotomy, the patient usually stays in the hospital for three to five days, unless there is a complicating condition. It takes about two weeks to recover fully from the surgery.

Preparation

Emergency tracheotomy

In the emergency tracheotomy, there is no time to explain the procedure or the need for it to the patient. The patient is placed on his or her back with face upward (supine), with a rolled-up towel between the shoulders. This positioning of the patient makes it easier for the doctor to feel and see the structures in the throat. A local anesthetic is injected across the cricothyroid membrane.

Nonemergency tracheotomy

In a nonemergency tracheotomy, there is time for the doctor to discuss the surgery with the patient, to explain what will happen and why it is needed. The patient is then put under general anesthesia. The neck area and chest are then disinfected as preparation for the operation, and surgical drapes are placed over the area, setting up a sterile field.

Aftercare

Postoperative care

A chest x ray is often taken, especially in children, to check whether the tube has become displaced or if complications have occurred. The doctor may prescribe antibiotics to reduce the risk of infection. If the patient can breathe on their own, the room is humidified; otherwise, if the tracheotomy tube is to remain in place, the air entering the tube from a ventilator is humidified. During the hospital stay, the patient and his or her family members will learn how to care for the tracheotomy tube, including suctioning and clearing it. Secretions are removed by passing a smaller tube (catheter) into the tracheotomy tube.

It takes most patients several days to adjust to breathing through the tracheotomy tube. At first, it will be hard even to make sounds. If the tube allows some air to escape and pass over the vocal cords, then the patient may be able to speak by holding a finger over the tube. A patient on a ventilator will not be able to talk at all.

The tube will be removed if the tracheotomy is temporary. Then the wound will heal quickly and only a small scar may remain. If the tracheotomy is permanent, the hole stays open and, if it is no longer needed, it will be surgically closed.

Home care

After the patient is discharged, he or she will need help at home to manage the tracheotomy tube. Warm compresses can be used to relieve pain at the incision site. The patient is advised to keep the area dry. It is recommended that the patient wear a loose scarf over the opening when going outside. He or she should also avoid contact with water, food particles, and powdery substances that could enter the opening and cause serious breathing problems. The doctor may prescribe pain medication and antibiotics to minimize the risk of infections. If the tube is to be kept in place permanently, the patient can be referred to a speech therapist in order to learn to speak with the tube in place. The tracheotomy tube may be replaced four to 10 days after surgery.

Patients are encouraged to go about most of their normal activities once they leave the hospital. Vigorous activity is restricted for about six weeks. If the tracheotomy is permanent, further surgery may be needed to widen the opening, which narrows with time.

Risks

Immediate risks

There are several short-term risks associated with tracheotomies. Severe bleeding is one possible complication. The voice box or esophagus may be damaged during surgery. Air may become trapped in the surrounding tissues or the lung may collapse. The tracheotomy tube can be blocked by blood clots, mucus, or the pressure of the airway walls. Blockages can be prevented by suctioning, humidifying the air, and selecting the appropriate tracheotomy tube. Serious infections are rare.

Long-term risks

Over time, other complications may develop following a tracheotomy. The windpipe itself may become damaged for a number of reasons, including pressure from the tube; bacteria that cause infections and form scar tissue; or friction from a tube that moves too much. Sometimes the opening does not close on its own after the tube is removed. This risk is higher in tracheotomies with tubes remaining in place for 16 weeks or longer. In these cases, the wound is surgically closed.

High-risk groups

The risks associated with tracheotomies are higher in the following groups of patients:

• children, especially newborns and infants
• smokers
• alcoholics
• obese adults
• persons over 60
• persons with chronic diseases or respiratory infections
• persons taking muscle relaxants, sleeping medications, tranquilizers, or cortisone

The overall risk of death from a tracheotomy is less than 5%.