Related to this topic: Support | UK Guidelines | Weblinks | Equipment | Books | Your Experience | Other resources | Glossaries
Print options: Printer friendly version of this leaflet (html)     Other options:  AddThis Social Bookmark Button (what's this?)

PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Tracheostomy - Indications, Procedure and Subsequent Management

Description

A tracheostomy provides direct access to the trachea by surgically making an opening in the neck. Once an opening is made it needs to be maintained usually via a tracheostomy tube.

Indications for a tracheostomy
  • Obstruction of the upper airway e.g. foreign body, trauma, infection, laryngeal tumour, facial fractures
  • Impaired respiratory function e.g. head trauma leading to unconsciousness, bulbar poliomyelitis
  • To assist weaning from ventilatory support in patients on intensive care
  • To help clear secretions in the upper airway

Comparison of tracheostomy and endotracheal intubation
Comparison of tracheostomy and endotracheal intubation
Tracheostomy
Endotracheal intubation
Reduced need for sedation Easier and quicker to perform compared with tracheostomy
Reduced damage to glottis Tolerated well for short periods
Reduced work of breathing (by reducing dead space) Weaning more difficult after long period of placement
Reduced patient discomfort Need to be sedated
More invasive and complicated compared with endotracheal tube placement Prevents aspiration of secretions
Scar formation Can be used to give certain medications e.g. adrenalin
Tracheostomy site can bleed or become infected Need to warm and filter gases as bypass the nose which would normally provide this function
Requires skill to perform the procedure Improper placement can occur e.g. oesophageal placement
May be associated with long-term complications e.g. swallowing difficulties  
Procedure

Tracheostomy can be performed in theatres (open surgical tracheostomy) or at the bedside (percutaneous dilational tracheostomy) as is common on intensive care units. Furthermore, a meta analysis concluded that percutaneously dilated tracheostomy is the procedure of choice in acute ICU patients.1

Surgical tracheostomy2

  • Patient supine with head extension and under general anaesthesia
  • Incision 2-3 cm from second tracheal ring down
  • Divide thyroid isthmus if needed
  • Make hole between 3rd and 4th tracheal rings, removing anterior portion of tracheal ring
  • Tracheostomy tube inserted

Percutaneous tracheostomy2

  • Percutaneous placement of a tracheostomy is performed using guide-wires and dilators
  • Guidewire placed between first and second tracheal ring
  • Gradually hole size increased using dilators of varying sizes which are passed over the guidewire
  • This can be performed blindly in experience hands but often is aided by the use of a bronchoscope

There are various other methods also available both for surgical and percutaneous dilational tracheostomy.2

A mini-Trach is a tracheostomy tube of a smaller diameter that is passed through the crico-thyroid membrane. It is usually employed during emergency situations when intubation fails.

Complications3,4
  • Immediate
  • Early
    • Tube obstruction or displacement
    • Aspiration
    • Bleeding from tracheostomy site
    • Infection
  • Late
    • Airway obstruction with aspiration
    • Damage to larynx e.g. stenosis
    • Tracheal stenosis
    • Tracheomalacia
    • Aspiration and pneumonia
    • Fistula formation e.g. tracheo-cutaneous or tracheo-oesophageal

Once a tracheostomy is removed the stoma usually heals over with time although a scar often remains.

Care of a patient with a short-term tracheostomy
  • Meticulous care towards hygiene and asepsis
  • Speaking - once the cuff can be deflated, the patient can begin to speak if the opening is occluded. Usually this takes time and patients need lots of support.
  • Removal - as the patient improves the tracheostomy can be plugged for longer durations each day provided the patient can tolerate it.
  • Swallowing - oral intake can occur but swallowing may be difficult. Patients must be watched for aspiration risk.
Care of a patient with a long-term tracheostomy5
  • Educate patient and carers
  • Meticulous care towards hygiene and asepsis
  • Carers will need to be taught how to suction and replace outer tubes
  • Providing humidification
  • Management regarding speaking and eating as above

Future aspects

There is some concern that evaluation of the morbidity and outcomes of patients with a tracheostomy has not at present, been adequately investigated. Rather, some data suggests that having a tracheostomy although popularly held to make weaning easier, does not impact on survival of ICU patients and may even be associated with increased mortality post-ICU.6,7 Perhaps selection criteria to chose patients who are likely to benefit from tracheostomy need to be established.7



Document References
  1. Delaney A, Bagshaw SM, Nalos M; Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care. 2006;10(2):R55. [abstract]
  2. Durbin CG Jr; Techniques for performing tracheostomy. Respir Care. 2005 Apr;50(4):488-96. [abstract]
  3. Durbin CG Jr; Early complications of tracheostomy. Respir Care. 2005 Apr;50(4):511-5. [abstract]
  4. Epstein SK; Late complications of tracheostomy. Respir Care. 2005 Apr;50(4):542-9. [abstract]
  5. Dhand R, Johnson JC; Care of the chronic tracheostomy. Respir Care. 2006 Sep;51(9):984-1001; discussion 1002-4. [abstract]
  6. Clec'h C, Alberti C, Vincent F, et al; Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Crit Care Med. 2007 Jan;35(1):132-8. [abstract]
  7. L'Her E; Tracheostomy: may the truth be out there? Crit Care Med. 2007 Jan;35(1):309-10.
Internet and Further Reading Acknowledgements EMIS is grateful to Dr Gurvinder Rull for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 2881
Document Version: 21
DocRef: bgp24476
Last Updated: 21 Mar 2007
Review Date: 20 Mar 2009
Patient UK Current Health News










Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.

Advertise on this site

PS - Health and Poverty

Perhaps the biggest cause of ill health in the world is poverty. Help to Make Poverty History. For example, why not lend some of your money to disadvantaged communities to enable them to trade their way out of poverty through schemes such as Shared Interest.

See also MAKEPOVERTYHISTORY North East for details and links to campaigns against poverty.

^ Top of Page