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== '''Introduction''' ==
</div>
[[File:Tracheostomy NIH.jpeg|right|frameless|417x417px]]
A tracheostomy is a [[Surgery and General Anaesthetic|surgical]] opening in the anterior wall of the [[Trachea and Larynx|trachea]]. Traditionally a tracheostomy is performed as an open surgical procedure, however safe and reliable percutaneous tracheostomy techniques have been developed, allowing for the bedside placement of a tracheostomy in many patients<ref>Raimonde AJ, Westhoven N, Winters R. Tracheostomy.Available:https://www.ncbi.nlm.nih.gov/books/NBK559124/ (accessed 18.5.2022)</ref>.


== '''Introduction''' ==
This 6 minute video explains what a tracheotomy is.


A tracheostomy is a surgical opening in the anterior wall of the trachea. There are two types of tracheostomy; a percutaneous tracheostomy and a surgical tracheostomy.
{{#ev:youtube|ULb5q6aBuic|300}}


==== '''Percutaneous Tracheostomy''' ====
==== '''Percutaneous Tracheostomy''' ====


A percutaneous tracheostomy has been formed by stretching (dilating) the tissues which will spring back into their original places if the tube is removed. A percutaneous tracheostomy is generally preferred to surgical tracheostomy in intensive care patients as it can be performed on the ICU, thus eliminating the logistical problems that may occur when transferring a ventilated patient to the operating theatre. There are six different techniques that are commonly performed can be distinguished:multiple dilator tracheostomy, rotational dilation tracheostomy, and translaryngeal tracheostomy.
Percutaneous Tracheostomy involves Seldinger technique and dilatation of trachea between rings<ref name=":1">Life in the fast lane Available: https://litfl.com/percutaneous-tracheostomy/ (accessed 18.5.2022)</ref>.
 
===== '''Balloon dilatational technique''' =====
 
This involves the same initial stages as the Single tapered dilatational technique, but instead of a curved dilator a pressurised balloon is used to dilate the trachea to allow passage of the tracheostomy tube.
 
===== '''Guide wire forceps (Griggs technique)''' =====
 
Following the insertion of a guide wire, dilator forceps are advanced alongside the wire and into the trachea. These forceps are then opened splitting the tracheal membrane to the desired diameter to allow insertion of the tracheostomy tube.


===== '''The Ciaglia serial dilatational technique''' =====
A percutaneous tracheotomy (PT) is typically performed in a hospital room. The doctor makes a small incision near the base of the front of the neck. A special lens is fed through the mouth so that the surgeon can view the inside of the throat. Using this view of the throat, the surgeon guides a needle into the windpipe to create the tracheostomy hole, then expands it to the appropriate size for the tube<ref name=":2">Mayo clinic Tracheostomy Available: https://www.mayoclinic.org/tests-procedures/tracheostomy/about/pac-20384673<nowiki/>(accessed 18.5.2022)</ref>. Bedside PT generates significant cost savings by eliminating operating room and anesthesia charges. Bronchoscopy is commonly used as a visual aid during PT. Ultrasound (US)-guided PT is gaining popularity<ref>Al-Shathri Z, Susanto I. Percutaneous tracheostomy. InSeminars in Respiratory and Critical Care Medicine 2018 Dec (Vol. 39, No. 06, pp. 720-730). Thieme Medical Publishers.Available: https://pubmed.ncbi.nlm.nih.gov/30641590/<nowiki/>(accessed 18.5.2022)</ref>. 
 
A cannula or needle is inserted into the trachea. The guide wire is then passed in a caudal direction before a primary dilator is passed over the wire to begin dilatation of the tract. A white plastic sheath is positioned over the wire to act as a guide for the dilators. The dilator must be inserted over the guiding catheter up to a safety ridge, this is necessary to prevent damage to the curved dilator tip and kinking of the guiding catheter. Dilators of increasing size are used and once the tract is sufficiently dilated, a tracheostomy tube loaded onto the appropriately sized dilator is passed over the guide wire and plastic sheath into the patient's trachea.
 
==== '''Single tapered dilatational technique''' ====
 
This is a modification of the Ciaglia technique and uses a single tapered dilator. The one-step dilatation is faster and is the commonest method of percutaneous tracheostomy used in the UK.<ref>Batuwitage B. Webber S. Glossop A.  Percutaneous tracheostomy, ''Continuing Education in Anaesthesia Critical Care & Pain'', 2014; 14:268 -272. <nowiki>https://doi.org/10.1093/bjaceaccp/mkt068</nowiki></ref>


==== '''Surgical Tracheostomy''' ====
==== '''Surgical Tracheostomy''' ====
 
Surgical Tracheostomy involves dissection and incision of trachea under direct vision<ref name=":1" />.[[File:Tracheostomy with tube.jpeg|thumb|Tracheostomy with tube]]
A surgical tracheostomy stoma is usually cut and stitched open and are more likely to have an established stoma within a day or 2 (or even straight away) after a tracheostomy.  
Surgical tracheotomy can be performed in an operating room or in a hospital room. The person is positioned on there back, and a rolled-up towel (or equivalent) is placed under your shoulders to help stretch persons neck. Local anaesthetic is injected into the target area, and a skin incision (cut) is made. The surgeon will then open either the trachea (this is called a ‘tracheostomy’) or the cricothyroid membrane - the thinnest part of the airway below the larynx (this is called a ‘cricothyroidotomy’). The airway tube is inserted into the trachea and person is connected to the oxygen supply. The entire procedure is done as quickly as possible<ref name=":2" />.   
 
'''Horizontal slit''' - a horizontal or T-shaped tracheal opening through the membrane between the second and third or third and fourth tracheal rings (Fig 1). With this incision, a silk stay suture can be placed through the tracheal wall on each side and taped to the neck skin on either side. This facilitates tube replacement by pulling the trachea anteriorly and widening the opening should the tube dislodge in the immediate postoperative period. These sutures are removed after the first tracheostomy tube change 5-7 days postoperatively once the newly formed tract from the skin to the trachea becomes more established.  
 
   


== Indications for a Tracheostomy<ref name=":0">NHS e-Learning for Healthcare and the Royal College of Anaesthetists. Understanding Tracheostomies and Laryngectomies. Available at https://cs1.e-learningforhealthcare.org.uk/content/NTSP_01_001/d/ELFH_Session/_/session.html#overview.html (accessed 23 May 2020)</ref> ==
== Indications for a Tracheostomy<ref name=":0">NHS e-Learning for Healthcare and the Royal College of Anaesthetists. Understanding Tracheostomies and Laryngectomies. Available at https://cs1.e-learningforhealthcare.org.uk/content/NTSP_01_001/d/ELFH_Session/_/session.html#overview.html (accessed 23 May 2020)</ref> ==
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* A tracheostomy is usually well tolerated and typically does not require sedation once it has been inserted.   
* A tracheostomy is usually well tolerated and typically does not require sedation once it has been inserted.   
* It is the best way of invasively ventilating a patient in the medium to long term, it provides a secure airway without directly interfering with the larynx
* It is the best way of invasively ventilating a patient in the medium to long term, it provides a secure airway without directly interfering with the [[Trachea and Larynx|larynx]]
* It can facilitate weaning from ventilation.
* It can facilitate [[Ventilation and Weaning|weaning from ventilation.]]
* It can enable long-term mechanical ventilation of patients, either in an acute setting or long term.
* It can enable long-term mechanical ventilation of patients, either in an acute setting or long term.


===== '''<nowiki/>Protecting the airway''' =====
===== '''<nowiki/>Protecting the airway''' =====


* Some patients are at high risk of aspirating secretions or gastric contents into the airway. E.g. neuromuscular disorders,  head injuries, unconsciousness, stroke or following prolonged disuse such as after trans-laryngeal intubation (Endotracheal Tube)
* Some patients are at high risk of aspirating secretions or gastric contents into the airway. E.g[[Neuromuscular Disorders|. neuromuscular disorders]],  [[Traumatic Brain Injury|head injuries]], unconsciousness, [[stroke]] or following prolonged disuse such as after trans-laryngeal intubation (Endotracheal Tube)
* A tracheostomy tube with the cuff inflated reduces the risk and offers some protection against aspiration
* A tracheostomy tube with the cuff inflated reduces the risk and offers some protection against aspiration
* Sub-glottic suction systems can help to reduce secretions that enter the airway
* Sub-glottic suction systems can help to reduce secretions that enter the airway
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* To facilitate the removal of bronchial secretions where there is poor cough effort with sputum retention
* To facilitate the removal of bronchial secretions where there is poor cough effort with sputum retention
* Tracheostomy allows manual insufflation-exsufflation ([[Assisted Coughing|cough assist]]) to be applied directly to the lungs
* Tracheostomy allows manual insufflation-exsufflation ([[Assisted Coughing|cough assist]]) to be applied directly to the [[Lung Anatomy|lungs]]
* Suction directly into the trachea to help clear secretions.<ref name=":0" />
* Suction directly into the trachea to help clear secretions.<ref name=":0" />
===== Other Reasons for a Tracheostomy<ref>The Johns Hopkins University. Reasons for a tracheostomy. Available from https://www.hopkinsmedicine.org/tracheostomy/about/reasons.html<nowiki/>(accessed 26 May 2020)</ref> =====
* Neuromuscular diseases paralyzing or weakening chest muscles and [[Diaphragm Anatomy and Differential Diagnosis|diaphragm]]
* Aspiration related to muscle or sensory problems in the throat
* Fracture of cervical vertebrae with [[Spinal Cord Injury|spinal cord injury]]
* Long-term unconsciousness or coma
* Disorders of respiratory control such as congenital central hypoventilation or central apnea
* Facial surgery and facial [[Burns Overview|burns]]
* Anaphylaxis (severe allergic reaction)
== Physiological Changes ==
* The upper airway anatomical dead space can be reduced by up to 50%. - This space takes no part in gas exchange and adds to the work of breathing. Reducing this can help patients wean off a ventilator more easily.
* The natural warming, humidification and filtering of air that usually takes place in the upper airway is lost
* The patient's ability to speak is removed/reduced as the cuff impairs the swallowing mechanisms of the larynx
* The ability to swallow is adversely affected
* Sense of taste and smell can be lost which can have a negative impact on appetite.
* Altered body image<ref name=":0" />


== Complications ==
== Complications ==


=== '''Resources''' ===
===== '''Perioperative period''' =====
* Haemorrhage
* Misplacement of tube - within tissues around trachea or to main bronchus
* [[Pneumothorax]]
* Tube occlusion
* Surgical emphysema
* Loss of the upper airway
 
===== '''Postoperative period < 7 days''' =====
* Tube blockage with secretions or blood
* Partial or complete tube displacement
* Infection of the stoma site
* Infection of the bronchial tree ([[pneumonia]])
* Ulceration, and/or necrosis of trachea or mucosal ulceration by tube migration
* Risk of occlusion of the tracheostomy tube in obese or fatigued patients who have difficulty extending their neck
* Tracheo-oesophageal fistula formation
* Haemorrhage
 
===== '''Late postoperative period >7 days''' =====
* Granulomata (a mass of granulation tissue) of the trachea may cause respiratory difficulty when the tracheostomy tube is removed
* Tracheal dilation, stenosis or tracheomalacia (trachea partly collapses especially during increased airflow)
* Scar formation-requiring revision
* Haemorrhage
 
== Types of Tubes ==
 
===== Cuffed with fenestrated tubes =====
Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak


 <nowiki/>'''UK National Tracheostomy Safety Project'''  http://www.tracheostomy.org.uk/
===== Cuffed with unfenestrated tubes =====
=== Related articles ===
Used to obtain a closed circuit for ventilation


Template:Substitute: New Page - Physiopedia Introduction Sub Heading 2 Sub Heading 3 Resources bulleted list x or numbered list xTemplate:Subst-New Page - PhysiopediaIntroduction Sub Heading 2 Sub Heading 3 Resources bulleted list x or numbered list xParalympic Sport Classification - PhysiopediaIntroduction Sub Heading 2 Sub Heading 3 Resources bulleted list x or numbered list xWheelchair Skills Assessment - PhysiopediaIntroduction Sub Heading 2 Sub Heading 3 Resources bulleted list x or numbered list xTreacher Collins Syndrome (TCS) - PhysiopediaIntroduction Sub Heading 2 Sub Heading 3 Resources bulleted list x or numbered list x
===== Uncuffed with fenestrated tubes =====
Used for patients who have difficulty using a speaking valve


'''References'''
===== Uncuffed with unfenestrated tubes =====
Used for patients with tracheal problems


== Sub Heading 2 ==
Used for patients who are ready for decannulation


== Sub Heading 3 ==
Patient may be able to eat and may be able to talk without a speaking valve.


=== Resources ===
{{#ev:youtube|KBbpxsznEPc|300}}<ref>National Tracheostomy Safety Project. Understanding Tracheostomy Tubes (National Tracheostomy Safety Project). Available from https://www.youtube.com/watch?v=KBbpxsznEPc (Accessed May 31st 2020)</ref>


* bulleted list
=== '''Resources''' ===
* x
<nowiki/>UK National Tracheostomy Safety Project  http://www.tracheostomy.org.uk/
or
# numbered list
# x
Related articles


Template:Substitute: New Page - PhysiopediaIntroduction Sub Heading 2 Sub Heading 3 Resources bulleted list x or numbered list xTemplate:Subst-New Page - PhysiopediaIntroduction Sub Heading 2 Sub Heading 3 Resources bulleted list x or numbered list xParalympic Sport Classification - PhysiopediaIntroduction Sub Heading 2 Sub Heading 3 Resources bulleted list x or numbered list xWheelchair Skills Assessment - PhysiopediaIntroduction Sub Heading 2 Sub Heading 3 Resources bulleted list x or numbered list xTreacher Collins Syndrome (TCS) - PhysiopediaIntroduction Sub Heading 2 Sub Heading 3 Resources bulleted list x or numbered list x
Watch a Tracheostomy https://www.hopkinsmedicine.org/tracheostomy/video/watching.html


=== References ===
=== References ===
<references />
<references />
[[Category:Respiratory]]
[[Category:Critical Care]]
[[Category:Interventions]]
[[Category:Respiratory Disease - Interventions]]
[[Category:Acute Care]]
[[Category:Cardiopulmonary - Interventions]]
[[Category:Cardiopulmonary]]

Latest revision as of 03:04, 18 May 2022

Original Editor - Natalie Patterson Top Contributors - Natalie Patterson, Lucinda hampton and Kim Jackson

Introduction[edit | edit source]

Tracheostomy NIH.jpeg

A tracheostomy is a surgical opening in the anterior wall of the trachea. Traditionally a tracheostomy is performed as an open surgical procedure, however safe and reliable percutaneous tracheostomy techniques have been developed, allowing for the bedside placement of a tracheostomy in many patients[1].

This 6 minute video explains what a tracheotomy is.

Percutaneous Tracheostomy[edit | edit source]

Percutaneous Tracheostomy involves Seldinger technique and dilatation of trachea between rings[2].

A percutaneous tracheotomy (PT) is typically performed in a hospital room. The doctor makes a small incision near the base of the front of the neck. A special lens is fed through the mouth so that the surgeon can view the inside of the throat. Using this view of the throat, the surgeon guides a needle into the windpipe to create the tracheostomy hole, then expands it to the appropriate size for the tube[3]. Bedside PT generates significant cost savings by eliminating operating room and anesthesia charges. Bronchoscopy is commonly used as a visual aid during PT. Ultrasound (US)-guided PT is gaining popularity[4].

Surgical Tracheostomy[edit | edit source]

Surgical Tracheostomy involves dissection and incision of trachea under direct vision[2].

Tracheostomy with tube

Surgical tracheotomy can be performed in an operating room or in a hospital room. The person is positioned on there back, and a rolled-up towel (or equivalent) is placed under your shoulders to help stretch persons neck. Local anaesthetic is injected into the target area, and a skin incision (cut) is made. The surgeon will then open either the trachea (this is called a ‘tracheostomy’) or the cricothyroid membrane - the thinnest part of the airway below the larynx (this is called a ‘cricothyroidotomy’). The airway tube is inserted into the trachea and person is connected to the oxygen supply. The entire procedure is done as quickly as possible[3].

Indications for a Tracheostomy[5][edit | edit source]

Airway obstruction[edit | edit source]
  • To secure and clear the airway in upper respiratory tract obstruction
  • An obstruction, often caused by a cancer, swelling of the airway, infection, inflammation or trauma
  • Where an airway is predicted to get worse and possibly become actually obstructed E.g. after major head and neck surgery
Providing an artificial airway for ventilation[edit | edit source]
  • A tracheostomy is usually well tolerated and typically does not require sedation once it has been inserted.
  • It is the best way of invasively ventilating a patient in the medium to long term, it provides a secure airway without directly interfering with the larynx
  • It can facilitate weaning from ventilation.
  • It can enable long-term mechanical ventilation of patients, either in an acute setting or long term.
Protecting the airway[edit | edit source]
  • Some patients are at high risk of aspirating secretions or gastric contents into the airway. E.g. neuromuscular disorders, head injuries, unconsciousness, stroke or following prolonged disuse such as after trans-laryngeal intubation (Endotracheal Tube)
  • A tracheostomy tube with the cuff inflated reduces the risk and offers some protection against aspiration
  • Sub-glottic suction systems can help to reduce secretions that enter the airway
Respiratory secretion management[edit | edit source]
  • To facilitate the removal of bronchial secretions where there is poor cough effort with sputum retention
  • Tracheostomy allows manual insufflation-exsufflation (cough assist) to be applied directly to the lungs
  • Suction directly into the trachea to help clear secretions.[5]
Other Reasons for a Tracheostomy[6][edit | edit source]
  • Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm
  • Aspiration related to muscle or sensory problems in the throat
  • Fracture of cervical vertebrae with spinal cord injury
  • Long-term unconsciousness or coma
  • Disorders of respiratory control such as congenital central hypoventilation or central apnea
  • Facial surgery and facial burns
  • Anaphylaxis (severe allergic reaction)

Physiological Changes[edit | edit source]

  • The upper airway anatomical dead space can be reduced by up to 50%. - This space takes no part in gas exchange and adds to the work of breathing. Reducing this can help patients wean off a ventilator more easily.
  • The natural warming, humidification and filtering of air that usually takes place in the upper airway is lost
  • The patient's ability to speak is removed/reduced as the cuff impairs the swallowing mechanisms of the larynx
  • The ability to swallow is adversely affected
  • Sense of taste and smell can be lost which can have a negative impact on appetite.
  • Altered body image[5]

Complications[edit | edit source]

Perioperative period[edit | edit source]
  • Haemorrhage
  • Misplacement of tube - within tissues around trachea or to main bronchus
  • Pneumothorax
  • Tube occlusion
  • Surgical emphysema
  • Loss of the upper airway
Postoperative period < 7 days[edit | edit source]
  • Tube blockage with secretions or blood
  • Partial or complete tube displacement
  • Infection of the stoma site
  • Infection of the bronchial tree (pneumonia)
  • Ulceration, and/or necrosis of trachea or mucosal ulceration by tube migration
  • Risk of occlusion of the tracheostomy tube in obese or fatigued patients who have difficulty extending their neck
  • Tracheo-oesophageal fistula formation
  • Haemorrhage
Late postoperative period >7 days[edit | edit source]
  • Granulomata (a mass of granulation tissue) of the trachea may cause respiratory difficulty when the tracheostomy tube is removed
  • Tracheal dilation, stenosis or tracheomalacia (trachea partly collapses especially during increased airflow)
  • Scar formation-requiring revision
  • Haemorrhage

Types of Tubes[edit | edit source]

Cuffed with fenestrated tubes[edit | edit source]

Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak

Cuffed with unfenestrated tubes[edit | edit source]

Used to obtain a closed circuit for ventilation

Uncuffed with fenestrated tubes[edit | edit source]

Used for patients who have difficulty using a speaking valve

Uncuffed with unfenestrated tubes[edit | edit source]

Used for patients with tracheal problems

Used for patients who are ready for decannulation

Patient may be able to eat and may be able to talk without a speaking valve.

[7]

Resources[edit | edit source]

UK National Tracheostomy Safety Project http://www.tracheostomy.org.uk/

Watch a Tracheostomy https://www.hopkinsmedicine.org/tracheostomy/video/watching.html

References[edit | edit source]

  1. ↑ Raimonde AJ, Westhoven N, Winters R. Tracheostomy.Available:https://www.ncbi.nlm.nih.gov/books/NBK559124/ (accessed 18.5.2022)
  2. ↑ 2.0 2.1 Life in the fast lane Available: https://litfl.com/percutaneous-tracheostomy/ (accessed 18.5.2022)
  3. ↑ 3.0 3.1 Mayo clinic Tracheostomy Available: https://www.mayoclinic.org/tests-procedures/tracheostomy/about/pac-20384673(accessed 18.5.2022)
  4. ↑ Al-Shathri Z, Susanto I. Percutaneous tracheostomy. InSeminars in Respiratory and Critical Care Medicine 2018 Dec (Vol. 39, No. 06, pp. 720-730). Thieme Medical Publishers.Available: https://pubmed.ncbi.nlm.nih.gov/30641590/(accessed 18.5.2022)
  5. ↑ 5.0 5.1 5.2 NHS e-Learning for Healthcare and the Royal College of Anaesthetists. Understanding Tracheostomies and Laryngectomies. Available at https://cs1.e-learningforhealthcare.org.uk/content/NTSP_01_001/d/ELFH_Session/_/session.html#overview.html (accessed 23 May 2020)
  6. ↑ The Johns Hopkins University. Reasons for a tracheostomy. Available from https://www.hopkinsmedicine.org/tracheostomy/about/reasons.html(accessed 26 May 2020)
  7. ↑ National Tracheostomy Safety Project. Understanding Tracheostomy Tubes (National Tracheostomy Safety Project). Available from https://www.youtube.com/watch?v=KBbpxsznEPc (Accessed May 31st 2020)
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