Tracheostomy

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Introduction

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.

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.

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 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.

Surgical Tracheostomy

A surgical tracheostomy

A surgical tracheostomy stoma is usually cut and stitched open and you are more likely to have an established stoma within a day or 2 (or even straight away) after a tracheostomy.

Indications for a Tracheostomy

Airway obstruction

• 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

• Although requiring an invasive procedure to insert the tube, a tracheostomy is relatively well tolerated and typically does not require sedation.
• A tracheostomy is the best way of invasively ventilating a patient in the medium to long term, providing a secure airway without directly interfering with the larynx
• Tracheostomy can facilitate weaning from artificial ventilation in acute respiratory failure and prolonged ventilation. This means an overall gradual reduction in the support delivered by the ventilator

Tracheostomy can enable long-term mechanical ventilation of patients, either in an acute ICU setting or sometimes chronically in hospitals or in the community

'Protecting' the airway

• Some patients are at high risk of aspirating secretions or gastric contents into the airway. This includes those with impaired or incompetent laryngeal, pharyngeal or tongue movement or sensitivity. For example; neuromuscular disorders, unconsciousness, head injuries, stroke or following prolonged disuse such as after trans-laryngeal intubation
• No tube system completely eliminates the risks of aspiration
• A tracheostomy tube with the cuff inflated reduces the risk and offers a degree of protection against aspiration
• Sub-glottic suction systems can help to reduce secretions that enter the airway
• The benefits of cuff deflation on laryngeal rehabilitation are increasingly being realised. Adequate control of oral secretions and early cuff deflation can increase laryngeal function and cough strength, which in themselves can mitigate aspiration risks. Continual positive pressure flowing up from the lower airways (when a cuff is deflated) can also reduce the chances of aspiration
• Using a cuff for protection against aspiration is a multidisciplinary decision, involving the patient, medical teams, speech and language therapists and physiotherapists

Respiratory secretion management

• To facilitate the removal of bronchial secretions where there is poor cough effort with sputum retention
• Tracheostomy allows positive and/or negative pressure ('cough assist' devices) to be applied directly to the lungs
• Suction is possible directly into the trachea to help clear secretions as part of a comprehensive nursing and physiotherapy package of care

Complications

Resources

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

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