Tracheostomy

What is a tracheostomy?

A tracheostomy is an opening that is made through the skin in front of the neck into the windpipe (trachea).

Through this opening, a small tube called the tracheostomy tube is placed to assist with breathing. Tracheostomy can be performed at bedside by an ICU physician or by a surgeon in the operating room.

Why does one need a tracheostomy?

There are several reasons why a patient may need a tracheostomy but, in the ICU, the most common reason is the continued need to be on the breathing machine (ventilator) while he/she recovers from his/her underlying illness. Most physicians in the ICU will talk to you about tracheostomy in this context.

Other reasons that one may need a tracheostomy in the ICU are persistent swelling in the upper airway from surgery, radiation, infection or also from stroke which may affect your breathing indirectly because of one’s inability to clear secretions from poor cough or swallowing.

What are the advantages of doing tracheostomy?

While the ICU team always hope for patients to recover, sometimes performing a tracheostomy is necessary to help patients recover faster. Some of the following advantages are:

• Stopping the sleep medicines and waking up the patient. Patients tolerate tracheostomy tube much better than the breathing tube through the mouth.
• Engage in physical therapy.
• Assist in clearing secretions using a suction device.
• Reestablish communication. The patient may be able to mouth words initially but will be able to speak in most cases once the breathing machine is discontinued and the tracheostomy tube is closed with a special valve.
• Remove the breathing machine safely, and place it back immediately if needed should patients breathing worsens. This is preferable rather than re- inserting the breathing tube again in an emergency and restarting the sleeping medications just to tolerate the breathing tube.

What is the best time to do a tracheostomy?

The optimal time varies but is usually considered after 10-14 days of being on the breathing machine or sometimes even sooner depending how long the patient is expected to recover from his/her underlying illness.

Can we leave the breathing tube indefinitely?

Leaving the breathing tube in the windpipe longer than 14 days can damage the lining of the windpipe causing stenosis/blockage that may require surgery or in some cases permanent tracheostomy.

Can a patient speak with a tracheostomy? What about eating and drinking?

Eventually Yes. However, the following criteria will have to be met.

• Patient awake after stopping the sleep medicines. At this time, patient will be able to mouth words if he/she is alert and following commands.
• Patient must breathe spontaneously without the help of the breathing machine.
• Patient must tolerate capping of the tracheostomy tube. A special valve will then be attached to the tracheostomy tube that allows air to escape the vocal folds and not through the tracheostomy tube.
• A swallowing specialist will then evaluate the patient’s ability to swallow food. If a patient is deemed safe, then he/she may start a liquid or soft diet as tolerated

Note: A patient may not be able to speak or take any food by mouth if the illness specifically affects those functions (such as a stroke) or if the patient was not able to perform them prior to going on the breathing machine.

Is a tracheostomy permanent?

No. But it also depends on the underlying illness. Once the underlying illness is treated and patient continues to show progress in physical therapy, nutrition, and other aspects of breathing and coughing, the tracheostomy tube can be removed safely in time. The time to removal will therefore depend on the progress the patient makes.

However, it may be long term or permanent if the patient does not recover from his/her underlying illness – such as a stroke or anything that permanently damages patient’s ability to breathe or cough.

An appointment will be arranged with the specialist once the patient leaves the hospital.

What are the complications of performing a tracheostomy?

Like all procedures and surgeries done anywhere in the world, potential complications need to be discussed even though the rates of complications are extremely low.

• Most common complication after the procedure is bleeding. Most bleeding that occur are mild and expected to resolve. Rarely bleeding may be severe that may require surgery.
• Sometimes air can escape around the lungs or underneath the skin of the chest and neck while making an opening for the tracheostomy tube.
• Damage to the food pipe (esophagus).
• Damage to the vocal cords.
• Blockages in the tracheostomy tube – which can be cleared with suctioning.

Complications that can occur long term are accidental removal of tracheostomy tube, infection in the trachea, abnormal connection between the trachea and esophagus and sometimes formation of extra tissue at the site that may require surgery.

The ICU doctor will be happy to talk to you more if you have any unanswered questions or if you would like more explanation with certain aspects of the procedure.

Dr Shameen Salam - Department of Critical Care

Dr Anastasios Hantzakos – Department of Ear, Nose and Throat

Dr Yusuf Bayruk – Department of Thoracic Surgery