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Tracheotomy

Tracheotomy

Definition

A tracheotomy is a surgical procedure that opens up the windpipe (trachea). It is performed in emergency situations, in the operating room , or at bedside of critically ill patients. 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 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.


Demographics

Emergency tracheotomies are performed as needed in any person requiring one.


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 .

Surgical 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.


Diagnosis/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 and surgical drapes are placed over the area, setting up a sterile surgical 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 without a ventilator, 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. Special tracheostomy tubes are also available that facilitate speech.

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, infectious bacteria that forms 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. Increased secretions may occur in patients with tracheostomies, which require more frequent suctioning.


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

Normal results

Normal results include uncomplicated healing of the incision and successful maintenance of long-term tube placement.


Morbidity and mortality rates

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


Alternatives

For most patients, there is no alternative to emergency tracheotomy. Some patients with pre-existing neuromuscular disease (such as ALS or muscular dystrophy) can be sucessfully managed with emergency noninvasive ventilation via a face mask, rather than with tracheotomy. Patients who receive nonemergency tracheotomy in preparation for mechanical ventilation may often be managed instead with noninvasive ventilation, with proper planning and education on the part of the patient, caregiver, and medical staff.


Resources

books

bach, john r. noninvasive mechanical ventilation. nj: hanley and belfus, 2002.

fagan, johannes j., et al. tracheotomy. alexandria, va: american academy of otolaryngology-head and neck surgery foundation, inc., 1997.

"neck surgery." in the surgery book: an illustrated guide to 73 of the most common operations, ed. robert m. younson, et al. new york: st. martin's press, 1993.

schantz, nancy v. "emergency cricothyroidotomy and tracheostomy." in procedures for the primary care physician, ed. john pfenninger and grant fowler. new york: mosby, 1994.

other

"answers to common otolaryngology health care questions." department of otolaryngologyhead and neck surgery page. university of washington school of medicine [cited july 1, 2003]. <http://weber.u.washington.edu/~otoweb/trach.html>.

sicard, michael w. "complications of tracheotomy." the bobby r. alford department of otorhinolaryngology and communicative sciences. december 1, 1994 [cited july 1, 2003]. <http:www.bcm.tmc.edu/oto/grand/12194.html>.


Jeanine Barone, Physiologist Richard Robinson

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?



Tracheotomy is performed by a surgeon in a hospital.

QUESTIONS TO ASK THE DOCTOR



  • How do I take care of my trachesotomy?
  • How many of your patients use noninvasive ventilation?
  • Am I a candidate for noninvasive ventilation?

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Tracheotomy

Tracheotomy

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%.

Normal results

Normal results include uncomplicated healing of the incision and successful maintenance of long-term tube placement.

Resources

OTHER

"Answers to Common Otolaryngology Health Care Questions." Department of Otolaryngology-Head and Neck Surgery Page. University of Washington School of Medicine. http://weber.u.washington.edu/otoweb/trach.html.

Sicard, Michael W. "Complications of Tracheotomy." The Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences. http:www.bcm.tmc.edu/oto/grand/12194.html.

KEY TERMS

Cartilage A tough, fibrous connective tissue that forms various parts of the body, including the trachea and larynx.

Cricothyroidotomy An emergency tracheotomy that consists of a cut through the cricothyroid membrane to open the patient's airway as fast as possible.

Larynx A structure made of cartilage and muscle that connects the back of the throat with the trachea. The larynx contains the vocal cords.

Trachea The tube that leads from the larynx or voice box to two major air passages that bring oxygen to each lung. The trachea is sometimes called the windpipe.

Ventilator A machine that helps patients to breathe. It is sometimes called a respirator.

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Tracheotomy

Tracheotomy

A tracheotomy is a potentially life-saving surgical procedure. During a tracheotomy, an opening is made in a patient's windpipe to relieve airway obstruction. A tube inserted into the trachea through the throat allows breathing to continue through the tube and bypasses the mouth and nasal passages. After the emergency has passed, the tube can be removed and the opening closed.

The first tracheotomy was performed in 1825 by French physician Pierre Bretonneau (1778-1862). Bretonneau operated on a four-year-old girl whose throat had become obstructed with the scar tissue, the result of diphtheria (a disease characterized by weakness, high fever, and the for-mation of membrane-like throat obstructions). Although Bretonneau had previously attempted two failed tracheotomies, his determination, skill, and dexterity paid off when he saved the girl's life.

Tracheotomies are used today to treat choking victims, as well as patients with severe burns, poliomyelitis, respiratory infections, and cancer.

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tracheotomy

tracheotomy (trākēŏt´əmē), surgical incision into the trachea, or windpipe. The operation is performed when the windpipe has become blocked, e.g., by the presence of some foreign object or by swelling of the larynx. A curved or flexible tube is inserted into the trachea to facilitate breathing. In diseases such as pneumonia that cause the lungs to fill with fluids, this same incision may be used to drain the lungs. A tracheostomy is the surgical formation of a rounded opening into the trachea and differs from a tracheotomy in that the former procedure establishes a permanent opening.

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tracheotomy

tracheotomy (tracheostomy) Surgical procedure in which an incision is made through the skin into the trachea to allow insertion of a tube to facilitate breathing. It is done either to bypass any disease or damage in the trachea, or to safeguard the airway if a patient has to spend a long time on a mechanical ventilator.

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tracheotomy

tra·che·ot·o·my / ˌtrākēˈätəmē/ (also tra·che·os·to·my / -ˈästəmē/ ) • n. (pl. -mies) Med. an incision in the windpipe made to relieve an obstruction to breathing.

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tracheotomy

tracheotomy (tray-ki-ot-ŏmi) n. see tracheostomy.

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tracheotomy

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Tracheotomy

Tracheotomy

Definition

A tracheotomy is surgery in which a cut is made into the skin of the throat and then into the windpipe (trachea). The surgeon inserts a breathing tube into the opening. The purpose may be to bypass an obstruction (such as a chunk of meat stuck in the throat) and thus allow air to get into the lungs, or it may be to remove secretions.

Since about 1950, the term "tracheostomy" has been preferred to "tracheotomy," but many surgeons still use the older term. The suffix "-tomy" is derived from the Greek for "cutting," and thus "tracheotomy" means simply "cutting the trachea." The Latin for "mouth," is os, oris, and so "tracheostomy" comes to mean "cutting an (artificial) mouth into the trachea." "Tracheostomy" thus has the advantage of being more specific than "tracheotomy."

Purpose

A tracheotomy is performed if there is a blockage in the pharynx or in the upper trachea, or if the patient is having problems with mucus and other secretions getting into the windpipe (trachea). There are many reasons why the pharynx or the upper trachea may be blocked. 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. Patients who need help to breathe may be in a coma, or, because of spinal injury affecting the cervical nerves that control breathing, the patients may need a ventilator to pump air into the lungs for a long time.

Precautions

Doctors perform emergency tracheotomies as last-resort procedures. They are only done 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: emergency tracheotomies and non-emergency (elective) tracheotomies. The first is done only in extreme emergency situations and must be performed quite rapidly. It may be done anywhere, even in a restaurant, if the person would likely die while being transported to a proper operating room. The surgeon (sometimes, a non-surgeon must perform the tracheotomy) makes a cut into 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 cricothyrotomy. Cricothyrotomy is associated with a few immediate complications, such as hemorrhage and collapsed lung (pneumothorax).

Non-emergency (elective) tracheotomy

The second type of tracheotomy takes more time and is usually done in an operating room. The most common reason for performing a non-emergency (elective) tracheotomy is the need for the patient to undergo long-term mechanical ventilation. In this situation, the tracheotomy replaces a tube which had been inserted into the trachea through the patient's nose or mouth (an endotracheal tube). Other valid reasons for non-emergency (elective) tracheotomy include life-threatening aspiration pneumonia, poor clearance of bronchial secretions, and sleep apnea.

The surgical procedure itself is basically the same in the emergency and non-emergency (elective) tracheotomy. The surgeon first makes a cut (incision) into the skin of the neck that lies over the trachea. This incision is made in the lower part of the neck, between the Adam's apple and the top of the breast-bone. 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 breathing tube (tracheotomy tube), is inserted through the opening. This tube acts as an artificial windpipe and thus allows the patient to breathe. Oxygen or a mechanical ventilator may be hooked up to the tube to bring oxygen more effectively to the lungs. A dressing is placed around the opening. Tape or stitches (sutures) are used to hold the tube in place.

After a non-emergency tracheotomy, the patient usually stays in the hospital for one or two days, unless there is a complicating condition.

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 (if available) 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 (if available, for example in the emergency room of a hospital, but not in a proper operating room) is injected across the cricothyroid membrane. In a setting such as a restaurant, a rescue worker would cut without anesthesia. If the person would otherwise die within five minutes from lack of oxygen, the pain and risks are justified.

Non-emergency (elective) tracheotomy

In a non-emergency tracheotomy, there is time for the doctor to discuss the surgery with the patient, to explain what will happen and why it is needed, and to get the patient's informed consent. The patient is then given anesthesia (sometimes general, sometimes local or topical). 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, of course, in any patient when complications are known to have occurred. The doctor may prescribe antibiotics to reduce the risk of infection. If the patient can breathe on his or her own, the whole 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 handle the problems that the tracheotomy tube causes, including mechanically sucking mucus out of the throat and keeping the tube itself clear. Tracheotomy initially prevents easy swallowing because the larynx is no longer elevated. Secretions are removed by passing a smaller, sterile tube (catheter) into the tracheotomy tube and extending it down into one of the two main bronchi. The tracheotomy tube itself generally requires several cleanings every day. An aseptic, or preferably a sterile, technique must be used. It is important that the skin around the opening (stoma) be carefully maintained to prevent secondary infection and disintegration caused by moisture (such softening and disintegration is called "maceration").

It takes most patients several days to adjust to breathing through the tracheotomy tube. At first, it will be hard even to make non-speech 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 briefly 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 intended to be permanent, the hole stays open. If eventually 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 briefly to relieve pain at the incision site. However, in general, the patient is advised to keep the area dry, lest prolonged moisture cause disintegration of the skin (maceration).

It is recommended that the patient wear a loose scarf over the opening when going outside. He or she must drink fluids to avoid dehydration and must eat to maintain proper nutrition. At the same time, he or she must keep water, other fluids, small food particles, and powdery substances from entering the tube and thus causing 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 changed four to ten days after surgery.

Patients are encouraged to resume most of their normal activities once they leave the hospital. Vigorous activity is restricted for about six weeks. However, swimming and rough contact sports would be life-threatening. Even when taking a shower, the patient must keep the tracheotomy covered. 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 the esophagus may be damaged during surgery. Air may become trapped in the tissues surrounding a lung, causing it to 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 unless suction tubes are inserted without aseptic (or preferably sterile) technique. In cases of such carelessness, one is introducing bacteria into the suction catheter.

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, if the breathing tube is to be removed because it is no longer necessary, 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 and other substance-abusers
  • obese adults
  • persons over 60
  • persons with chronic respiratory 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%.

Results

Normal results include uncomplicated healing of the incision (even in an emergency tracheotomy) and successful maintenance of long-term tube placement in a non-emergency (elective) tracheotomy.

Health care team roles

A variety of allied health personnel is likely to be involved in the care of patients requiring a tracheotomy. In the case of an emergency tracheotomy, an emergency-room nurse or nurse anesthetist will assist the surgeon. A respiratory nurse or therapist will provide information to the patient and family about how to properly clean and maintain the tracheotomy tube if the tube is to be used long-term. This specialist will also provide information about administration of food and water and other issues. A nurse will likely provide information to the patient about how to prevent infection at the site of tube placement. A nurse specializing in the healing of wounds may work with the patient whether the tube is intended to be shortterm or long-term. In many cases, a speech therapist is used to help the patient resume verbal communication following the trauma of the tracheotomy. This is more likely to occur in patients who will need long-term mechanical ventilation.

KEY TERMS

Cartilage— A tough, fibrous connective tissue that forms various parts of the body, including the trachea and the larynx.

Cricothyrotomy— An emergency tracheotomy that consists of a cut through the cricothyroid membrane to open the patient's airway as quickly as possible.

Larynx— A structure in the throat made basically of cartilage, ligaments, and muscle, that connects the pharynx with the trachea. The larynx contains the vocal cords.

Maceration— Softening and eventual disintegration of tissue because of constant exposure to moisture.

Stoma— Artificially created opening between a body cavity and the surface of the body. ("Stoma" is Greek for the mouth.)

Trachea— The tube made of cartilage and other connective tissue that leads from the voice box (larynx) to two major air passages (the main bronchi) that bring oxygen to the lungs. The trachea is sometimes called the windpipe.

Ventilator— A machine that helps patients to breathe. It is sometimes called a respirator.

Resources

BOOKS

Fagan, Johannes J., et al. Tracheotomy. Alexandria, VA: American Academy of Otolaryngology—Head and Neck Surgery Foundation, 1997.

"Foreign Bodies of the Larynx and Tracheobronchial Tree." In Current Surgical Diagnosis and Treatment. Norwalk, CT: Appleton & Lange, 1994.

"Tracheotomy and Cricothyrotomy." In Current Medical Diagnosis and Treatment 2001, edited by Lawrence M. Tierney, et al. New York: Lange, 2001.

OTHER

"Answers to Common Otolaryngology Health-Care Questions." University of Washington School of Medicine, Department of Otolaryngology—Head and Neck Surgery. 〈http:weber.u.washington.edu/∼otoweb/trach.html〉.

Sorce, James J. "Acute Airway Management and Tracheotomy." 〈http:hsinfo.ghsl.nwu.edu/otolink/trach.html〉.

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Tracheotomy

Tracheotomy

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

A tracheotomy is a surgical procedure that opens up the windpipe (trachea). It is performed in emergency situations, in the operating room, or at bedside of critically ill patients. 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 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.

Demographics

Emergency tracheotomies are performed as needed in any person requiring one.

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 crico-thyroid membrane. A tube is inserted and connected to an oxygen bag. This emergency procedure is sometimes called a cricothyroidotomy.

Surgical 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.

Diagnosis/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 and surgical drapes are placed over the area, setting up a sterile surgical 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 without a ventilator, 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. Special tracheostomy tubes are also available that facilitate speech.

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.

KEY TERMS

Cartilage— A tough, fibrous connective tissue that forms various parts of the body, including the trachea and larynx.

Cricothyroidotomy— An emergency tracheotomy that consists of a cut through the cricothyroid membrane to open the patient’s airway as fast as possible.

Larynx— A structure made of cartilage and muscle that connects the back of the throat with the trachea. The larynx contains the vocal cords.

Trachea— The tube that leads from the larynx or voice box to two major air passages that bring oxygen to each lung. The trachea is sometimes called the windpipe.

Ventilator— A machine that helps patients to breathe. It is sometimes called a respirator.

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

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Tracheotomy is performed by a surgeon in a hospital. In an emergency, a tracheotomy may be performed on the scene by another medical professional.

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, infectious bacteria that forms 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. Increased secretions may occur in patients with tracheostomies, which require more frequent suctioning.

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

Normal results

Normal results include uncomplicated healing of the incision and successful maintenance of long-term tube placement.

Morbidity and mortality rates

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

Alternatives

For most patients, there is no alternative to emergency tracheotomy. Some patients with pre-existing neuromuscular disease (such as ALS or muscular

QUESTIONS TO ASK THE DOCTOR

  • How do I take care of my tracheostomy?
  • How many of your patients use noninvasive ventilation?
  • Am I a candidate for noninvasive ventilation?

dystrophy) can be successfully managed with emergency noninvasive ventilation via a face mask, rather than with tracheotomy. Patients who receive nonemergency tracheotomy in preparation for mechanical ventilation may often be managed instead with noninvasive ventilation, with proper planning and education on the part of the patient, caregiver, and medical staff.

Resources

BOOKS

Bach, John R. Noninvasive Mechanical Ventilation. NJ:Hanley and Belfus, 2002.

Fagan, Johannes J., et al. Tracheotomy. Alexandria, VA: American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc., 1997.

“Neck Surgery.” In The Surgery Book: An Illustrated Guideto 73 of the Most Common Operations, ed. Robert M. Younson, et al. New York: St. Martin’s Press, 1993.

Schantz, Nancy V. “Emergency Cricothyroidotomy and Tracheostomy.” In Procedures for the Primary Care Physician, ed. John Pfenninger and Grant Fowler. NewYork: Mosby, 1994.

OTHER

“Answers to Common Otolaryngology Health Care Questions.” Department of Otolaryngology–Head and Neck Surgery Page. University of Washington School of Medicine [cited July 1, 2003]. http://weber.u.washington.edu/~otoweb/trach.html.

Sicard, Michael W. “Complications of Tracheotomy.” The Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences. December 1, 1994 [cited July 1, 2003]. http://www.bcm.tmc.edu/oto/grand/12194.html.

Jeanine Barone, Physiologist

Richard Robinson

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Within the “Cite this article” tool, pick a style to see how all available information looks when formatted according to that style. Then, copy and paste the text into your bibliography or works cited list.

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