What is Tracheostomy?
Overview of Tracheostomy
Tracheostomy procedures are performed more each year, with over 100,000 procedures performed in the US each year. This section will review the definition of tracheostomy, breathing with a tracheostomy tube, history of tracheostomy, indications for tracheostomy, the different tracheostomy procedures (surgical versus percutanous) and benefits of tracheostomy.
What is Tracheostomy?
Tracheotomy is the name of the surgical procedure to make an opening in the trachea (airway).
Tracheostomy is the resulting stoma (hole) through which a tracheostomy tube is typically inserted and secured to keep the airway patent (open). However, both terms are often used interchangeably.
A tracheostomy tube is typically placed through the stoma to provide access to the trachea for breathing and to remove secretions from the lungs. The tube enables airflow directly through the trachea rather than through the nose and mouth, bypassing the humidification and immune functions of the upper airway (nose, mouth and nasopharyngeal airway).
The word “trach” is a shortened term for either tracheotomy, tracheostomy or tracheostomy tube.
Normal Airflow During Breathing
Airflow During Breathing Through a Tracheostomy Tube
History of Tracheostomy
Tracheostomy is one of the oldest surgical procedures and has been documented on Egyptian artifacts as far back as 3600 BC. The first ‘modern’ surgical tracheostomy is commonly credited to Italian physician Antonio Brasavola, documented in 1596′ (Goodall, 1973). The procedure was originally only used for upper airway obstructions.
Despite it’s antiquity, tracheostomy was rarely performed until the 19th century, when it had more widespread acceptance and was a common procedure for children with diptheria. Chevalier Jackson, a Laryngologist from Pittsburgh, established the principals of the open tracheotomy procedure in 1909 and these have grossly remained unchanged til present date. The first percutaneous dilational procedure is credited to Ciaglia in 1985 (Engels, P., 2009).
Tracheostomy is one of the most frequently performed procedures in critically ill patients today.
Indications for Tracheostomy
A tracheostomy can be performed for many reasons. It is important to understand the reason an individual has a tracheostomy tube in order to properly treat the patient and to determine if and when it is safe to decannulate (remove the tracheostomy tube).
When the procedure was originally introduced, the purpose was to relieve upper airway obstruction. In modern medicine, the indications have expanded to include the following (National Tracheostomy Safety Project):
- to secure and maintain a patent (clear) airway in actual or potential upper airway obstruction, including sleep apnea
- to facilitate weaning from artificial ventilation in acute respiratory failure and prolonged ventilation
- to enable long-term mechanical ventilation of patients, in a variety of settings such as acute ICU setting or sometimes chronically in hospitals or in the community
- to secure and maintain a safe airway in patients with injuries to the face, head or neck and following certain types of surgery to the head and neck which may pose a threat to adequate ventilation through the upper airway
- to facilitate the removal of bronchial secretions when there is poor cough strength with sputum retention: to provide a direct entry port to suctioning and removal of secretions by introducing a catheter via the tracheostomy
- in an attempt to protect the airway of patients who are at gross risk of aspiration and unable to manage secretions, such as those with incompetent laryngeal and oral motor movements for swallowing e.g. some neuromuscular disorders, unconsciousness, head injuries, stroke etc. A tube with a cuff is inserted which can keep some secretions or aspirated material out of the airways that would otherwise enter the lungs. **Please note that the cuff of the tracheostomy tube does NOT prevent aspiration. Any material that has reached the cuff has already been aspirated. However, the cuff may aid with reducing the amount of material that has been aspirated from reaching the lungs. If the secretions are blocking the airway and the individual has an incompetent cough reflex, the tracheostomy tube bypasses the secretions.
A tracheostomy may be placed surgically or percutaneously. A surgical open tracheostomy and percutaneous dilational tracheostomy (PDT) both require similar anethesia, analgesia, positioning, and sterile technique. In both procedures, the patient is positioned supine with the neck extended (unless the patient requires cervical spine precautions)(Engels, 2009). Care should be taken that all equipment is at bedside and functioning adequately. Prior to insertion, the cuff of the tracheostomy tube should be tested to make sure it is working properly.
When the tracheostomy is an elective procedure, it is important to obtain consent for the procedure and to educate the patient on the rationale behind the decision for a tracheostomy. The patient should also be informed that postoperatively there will be a period of communication difficulty due to a lack of airflow through the vocal folds, resulting in aphonia (no voicing) or limited voicing. Complications of tracheostomy should also be reviewed.
An open tracheostomy procedure is performed in the operating room, typically under use of general anethesia. The patient is first optimally positioned and then important landmarks are identified including the thyroid notch, sternal notch and cricoid cartilage. The procedure involves making a 2-3cm horizontal or vertical incision between the sternal notch and thyroid cartilage (approximately over the second tracheal ring). Dissection continues down to the strap muscles, which are separated, exposing the isthmus of the thyroid gland and the trachea. The isthmus may be detracted or divided. The trachea can be entered vertically or horizontally with excision of a portion of the anterior wall or creation of a flap (Bjork flap) of the wall. The Bjork flap is created as a preventative measure, to aid in reinsertion of the tracheostomy tube in case of accidental dislodgement, especially in difficult airways or obesity (Moris, L et al, 2013). After the airway is confirmed to be intact by direct visualization, end tidal CO2, ease of ventilation and adequate oxygen saturations, the tracheostomy tube is secured (Engels, 2009).
Exclusion criteria are patients with prior neck surgery, distorted anatomy, morbid obesity, cervical irradiation, maxillofacial or neck trauma, difficult airway, marked coagulopathy, infection at the incision site, high ratio of positive end-expiratory pressure to fraction of inspired oxygen, and elevated intracranial pressure (Engels, 2009; Morris, L. et al, 2013). Tracheostomy in children is predominantly a surgical procedure, with percutaneous tracheostomy being performed infrequently and only considered feasible in children over 12 years old.
NOTE: The Intensive Care Society standards state that in every hospital a list should be kept of practitioners competent in undertaking percutaneous tracheostomy insertion.
The tract will take 7-10 days to mature after the percutanous procedure, compared with 2-4 days for a surgical tracheostomy. If there is accidental dislodgement in the early days following a percutanous tracheostomy, there is a higher likelihood that the stoma may close quickly versus the surgically placed tracheostomy tube is more likely to remain patent.
Timing of Tracheostomy
There is still much debate in the literature surrounding the topic of optimal tracheostomy timing. In the Tracman study, a multicentered randomized clinical trial, early tracheostomy (within 4 days) was not associated with improved mortality, decreased length of stay or significantly reduced complications. There is widespread agreement that if the patient has a prolonged need for an artificial airway, then insertion of the tracheostomy tube is the preferred approach.
Benefits of Tracheostomy
Tracheostomy is commonly performed when clinicians expect a patient will need prolonged mechanical ventilation. Up to one third of patients requiring prolonged mechanical ventilation now receive a tracheostomy (Young, 2013). Benefits of tracheostomy include reduced sedation, reduced trauma to the oropharynx and larynx, reduced work of breathing, improved clearance of pulmonary secretions, quicker weaning from mechanical ventilation, and reduced length of ICU and hospital stay (Rodriguez et al, 1990; Bouderka et al, 2004; Rumbak et al, 2004) as well as reduced incidence of nasocomial pneumonia and improved patient comfort (Young, 2013). The risks of the surgical procedure compared to the expected benefits should be weighed by the team managing the patient.
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