When the unthinkable happens to a loved one whether it be an accident or a major illness requiring hospitalization in the ICU (Intensive Care Unit) with a machine breathing for him/her, a procedure called a "tracheotomy" may be brought up at some point by the physicians. This webpage is to explain the why, what, and how of this operation in order to demystify this procedure and allow the caretakers to make an informed decision. In rare cases, patients with severe obstructive sleep apnea unresponsive to all other options may opt for this procedure as well.
Normally, a person breathes air thru the nose and mouth and into the lungs. When a person is "intubated," a tube is placed through the mouth and into the windpipe. A machine is than connected to the tube and "pushes" air through the tube and into the lungs so that the person doesn't have to put any effort into breathing... the machine does all the work of breathing.
Read about how a trach is cared for at home here.
WHAT is a Tracheostomy ("Trach")?
In a nutshell, a tracheostomy is a procedure whereby the surgeon makes a small hole in a patient's neck directly into the windpipe (trachea). Through this hole, a very short tube called a tracheostomy tube is inserted from the surface of the neck directly into the windpipe. The tracheostomy tube is usually about 3 inches long.
In cases of severe obstructive sleep apnea (OSA), a trach is the only operation guaranteed to cure a person of OSA.
WHY do a Trach?
Whenever a patient is anticipated to be on a breathing machine (called a ventilator) and intubated (breathing tube through the mouth) for more than 10 days, a tracheotomy is recommended for several reasons:
- It is MUCH easier for a patient to come off the breathing machine as it takes less effort to breathe with a trach versus a regular oral tube. Why? An oral tube is over 12 inches long whereas a trach tube is only about 3 inches long. If one tries to breathe through a regular length straw, it is much harder than breathing through a straw cut to only a few inches long.
- Risk of airway scarring (stenosis) is much smaller with a trach tube. Should stenosis occur, it may become a life-long issue to address with repeated surgeries needed every few months to years. It is better to avoid this problem by getting a trach sooner rather than later.
- Easier for the lungs to be cleared of any secretions. This makes recovering from a bad pneumonia or similar lung problem much easier.
There may be other reasons as well depending on the particulars of a given patient's illness.
Although this procedure may sound "scary" and many patients and their families automatically refuse to consider such a procedure, the following survey done on February 19, 2008 on physicians nationwide may be illuminating on how worthwhile having this procedure is to recovery. When US physicians were polled at what point they would consider a tracheostomy on themself or their loved one if prolonged intubation was expected, 50% stated trach should be done within the first 8 days of intubation of which 28% wanted it to be performed within 3-5 days. Only 15% would consider a trach after 12 days or longer intubation.
The other fact to consider is that a trach is TEMPORARY!!! Once the patient is strong enough to breath on their own, the trach tube can be removed and the hole in the neck will completely close up within a few weeks without need for another surgical procedure.
In a research article published in 2011, patients who underwent trach within 7 days of intubation experienced shorter duration of mechanical ventilation and shorter length of overall hospital stay without affecting mortality compared with patients who underwent trach after 7 days of intubation.
How is a Trach Performed?
The trach is performed under general anesthesia and takes about 15 minutes to perform. In essence, a 1.5 inch incision is created in the midline neck directly over the windpipe indicated by the black arrow in the photo. Dissection is carried down to the windpipe and a window created through which a trach tube is inserted.
Movies and TV shows often show an emergency trach being performed as part of the storyline, but be aware that they only sometimes get it totally right and usually contain some errors. Click to watch a medical review of such scenes.
|Neck is sterilized with betadine to clean the skin and than draped to prevent any contamination from the environment.|
|After the incision, underlying fat is removed.|
|Dissection is carried down to the windpipe which is completely exposed in this picture. One can see the faint outlines of 2 1/2 tracheal rings.|
|A small window is then created in the windpipe. In this picture, one can see the endotracheal tube inside the windpipe. This tube is slowly removed from the windpipe as the anesthesiologist pulls the tube out from the mouth.|
|Once the endotracheal tube is removed, the windpipe and surrounding area is completely suctioned of all secretions and blood.|
|The tracheostomy tube is then inserted and secured in place. That's it!|
The skin around the trach tube should be kept clean and clear of any secretions to prevent skin breakdown. At first, lots of suctioning of the trach tube may be required as the patient may be too weak to cough it out. This suctioning is accomplished by threading a soft and flexible tubing through the trach tube and down into the windpipe. Once the suction tube has been inserted, suctioning is performed which removes any accumulated secretions present.
The entire trach tube also needs to be changed regularly as it will become dirty with time. Changing a trach tube is quite straightforward once the surgeon feels the wound has healed adequately.
Between entire trach tube changes, the inner cannula should be changed as often as needed if it becomes dirty or clogged.
Read more about home trach care here.
What about Talking?
Once a patient is breathing adequately on their own and off the breathing machine, talking is possible with a trach tube by first deflating the trach tube balloon and putting a finger over the trach tube blocking any air from passing. This forces air to go out the voicebox and mouth (the natural way) and allows for speech. There are devices that can be placed over the trach tube opening so a patient does not have to keep using their finger to talk such as a Passey Muier Valve.
What about Eating?
As long as the cuff of the trach tube is completely deflated, one can eat by mouth just as if the trach is not there.
When Can a Trach be Removed?
A trach can be removed when a patient is able to breath with the trach tube completely plugged so no air passes through it. Prior to plugging the trach, the tube should be swapped out for a smaller size so that air has an easier time moving around it. Once the trach is plugged, air moves the normal way thru the nose and mouth. If the patient has difficulty breathing with the trach plugged, trach removal cannot happen yet.
What Happens After the Trach is Removed?
If the trach is removed within months of placement, the hole will close up on its own over a period of several weeks with an occlusive dressing in place (generally a large band-aid or vaseline gauze covered with gauze and tape). Click here to see a time-lapse photo series of a trach hole closing up over time. The key thing is to prevent any air leakage when talking or coughing by holding the dressing down. If there is air escape, this will prevent the hole from closing completely, a situation known as tracheo-cutaneous fistula. If the scar is unsightly or there is a persistent fistula, it can be easily corrected surgically which often occurs if the trach is removed years after placement.
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- How a Tracheostomy Hole Heals Closed (Time Lapse Photos)
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