Tracheostomy

Tracheostomy may be advised for many of the following stated conditions or problems:

• Restricted airway due to an accident or injury in the neck or face.
• Chronic lung diseases
• Anaphylaxis
• Neck or throat cancers
• Dysfunction of diaphragm
• State of coma
• Burns in the respiratory tract due to the inhalation of a corrosive substance.
• Defects in the airway at the time of birth
• Infections
• Tumors
• Paralysis of the vocal cords
• Burns on the face or any surgery
• Difficulty in breathing properly due to any swelling restricting the airway.
• Injured chest wall
• Severe injuries on the mouth or neck
• Injury of the voice box or larynx
• Long-term ventilator support i.e. more than 7 to 14 days.
• Blockage of the air tract due to swallowing of a foreign material
• In conditions, where the person is unable to cough up the mucous secretions through the throat and hence, might require a suctioning to clean the airway tract.
• Uninterrupted and easy supply of oxygen to the lungs in patients who are unconscious or not competent enough to breathe normally.

Tracheostomy is a safe surgical procedure but every surgical procedure does have some complications associated with it. Some of the complications associated with tracheostomy are as mentioned:

• Possibility of Trachea damage
• Heavy bleeding
• Hematoma or collecting of blood in the neck may lead to compression of the windpipe and may result in breathing difficulty.
• Pneumothorax or air between the lungs and the chest wall leads to pain, breathing difficulty or lung collapse.
• Improper positioning of the tracheostomy tube

There are also some problems associated, if the tracheostomy tube is placed for a very long time in the trachea:

• Formation of some abnormal tissues in the trachea
• Narrowing of the trachea
• Shifting of the tracheostomy tube from its location
• Bacterial colonization infections like pneumonia
• Blockage in the tracheostomy tube
• Abnormal development of a passage between esophagus and trachea. This may result in the entering of food and fluids into the lungs.
• Life-threatening bleeding from a passage created between the innominate artery and the trachea.

Some patients might require a tracheostomy, even after getting discharged from the hospital. In such cases, regular follow-ups and continuous monitoring is a must. The doctor will give instructions on the management of tracheostomy at home. In these cases, there might be some complications, which may need an urgent call to the doctor like:

• Swelling
• Redness
• Shifting of the position of the tracheostomy tube
• Bleeding from the site where tracheostomy is done
• Breathing difficulty from the trach tube
• Severe pain
• Discomfort with the trach tube

Preparations for tracheostomy depends on the type of procedure a patient is undergoing. If the procedure is done under general anesthesia then the doctor may advise some of the following points:

• Fasting for some hours before the procedure.
• The stomach and urinary bladder should be empty.
• Some medicines may also be asked to stop for some time before the tracheostomy.

After the procedure, the patient is asked to stay in the hospital for a few days.

During the procedure:

The tracheostomy is performed usually in the operation theatre under general anesthesia. Local anesthesia is used only if the doctor feels the airway might get compromised under general anesthesia.

The tracheostomy procedure can be of two types, minimally invasive tracheostomy and surgical tracheostomy.

• Minimally invasive tracheostomy – This type of tracheostomy can be performed in a hospital room. In this type of procedure, a small cut or incision is made in front but at a slightly lower part of the neck. The surgeon puts a small lens through the patient's mouth to see the throat clearly. Then the surgeon guides a fine needle into the trachea to make a tracheostomy opening. This opening is expanded to fit a tracheostomy tube inside. The tube is held firmly by a special neck strap attached to the face to prevent the falling of the tube into the trachea.
• Surgical tracheostomy – This type of procedure can be done either in the hospital room or operation theatre. In this type of procedure, the surgeon makes a cut or incision, horizontally. It is made in front but at a slightly lower part of the neck. The muscles of the neck are then opened or pulled and the surgeon then makes a small cut on the thyroid gland, which exposes the trachea. This hole or opening is expanded to fit a tracheostomy tube inside. The tube is held firmly by a special neck strap attached to the face to prevent the falling of the tube into the trachea.

After the procedure:

After the procedure is complete, the patient might have difficulty speaking or breathing, initially. But gradually, the problems will go away. The doctor might prescribe some medicines to decrease the stress of the patient. After the procedure, the patient is asked to stay in the hospital for a few days.

If the tracheostomy procedure is temporary, then the tracheostomy tube will be removed in some days as the doctor suggests.  The healing process also occurs very fast and leaves a small scar. In some cases, a surgical procedure is required to close or shut the tracheostomy site properly. This site is also known as a stoma.

However, if the tracheostomy procedure is permanent, then the hole created in the neck remains open. Some patients might require a tracheostomy even after getting discharged from the hospital. In such cases, regular follow-ups and continuous monitoring is a must. The doctor will give instructions on the management of tracheostomy at home and in case there are some complications, the doctor must be called immediately. Some of the complications, wherein the doctor must be consulted include abnormal heart rate, swelling and redness, formation of thick mucus, which may cause blockage of the trach tube, shifting of the position of the tracheostomy tube, bleeding from the site where tracheostomy is done, breathing difficulty from the trach tube, severe pain and discomfort with the trach tube.

The patients would need some time to get used to the breathing and speaking process with a tracheostomy tube. This is because usually the sound is produced when the air passes through the larynx, however, in the case of tracheostomy, the air does not pass through larynx anymore, hence, preventing to produce sounds.

Initially, the patients with the trach tubes will be able to only make some sounds but gradually will be able to communicate properly. The patient can also return back to the normal routine in some time but only after the doctor advises. In such cases, the patients can wear a loose scarf or any kind for covering over the tracheostomy opening or stoma.

Precautions are to be taken when the patient comes in contact with water, food particles, powder, cold air or dust. The doctor will give instructions to the patient and to the family members on the management of tracheostomy at home.

Q1. How to take proper care of the tracheostomy tube at home?

A1. The doctor or the nurse instructs and informs multiple steps to the patient and the family members, to take care of the trach tube at home. Multiple steps would have to be followed by the patient as mentioned below:

• Collect the following items together:
• Clean cotton swabs
• Sterile gloves
• Hydrogen peroxide
• Small clean brush or pipe cleaner
• Distilled water or normal saline
• Clean cloth and towel
• Tracheostomy tube ties
• Sterile scissors
• Mesh gauze fine pieces of 4*4 size
• Properly wash hands soap and water
• Sit or stand in front of a mirror comfortably to clearly see the stoma and put on the sterile gloves
• Suction the tracheostomy tube as told by the nurse or the doctor, and remove the inner cannula if present.
• Hold the inner cannula over the sink and pour hydrogen peroxide into and over it. This makes the inner cannula thoroughly clean. Then with the help of the small clean brush or pipe cleaner, clean the inner cannula properly. Then rinse the inner cannula with distilled water or normal saline.
• Let the inner cannula dry out completely with the help of mesh gauze fine pieces of 4*4 size.
• Place the inner cannula back to its position and lock it firmly.
• Remove and throw the old dressing around the neck. Carefully examine the skin and the trach opening for any hardness, foul smell, redness, swelling or drainage. In case the patient observes any of the above-mentioned signs, call the doctor immediately.
• Clean the outer parts of the cannula and the skin around the trach opening, with the help of cotton swabs half soaked in water and half soaked in hydrogen peroxide.
• Clean the hydrogen peroxide on the skin with a clean cloth dipped in normal saline or distilled water. With the help of a clean towel, dry out the outer parts of the cannula and the skin around the trach opening carefully.
• Change the tracheostomy tube ties. After placing the ties properly, put a mesh gauze under the trach tie and the neck portion properly by folding it.
• Remove the hand gloves and dispose them off. Thoroughly wash hands with soap and water. Wash the brush or the pipe cleaner properly with warm water and dry them.