Tracheotomy Health Article

Definition

A tracheotomy is surgery in which a cut is made into the skin of the throat and then into the windpipe (trachea). The surgeon inserts a breathing tube into the opening. The purpose may be to bypass an obstruction (such as a chunk of meat stuck in the throat) and thus allow air to get into the lungs, or it may be to remove secretions.

Since about 1950, the term "tracheostomy" has been preferred to "tracheotomy," but many surgeons still use the older term. The suffix "-tomy" is derived from the Greek for "cutting," and thus "tracheotomy" means simply "cutting the trachea." The Latin for "mouth," is os, oris, and so "tracheostomy" comes to mean "cutting an (artificial) mouth into the trachea." "Tracheostomy" thus has the advantage of being more specific than "tracheotomy."

Purpose

A tracheotomy is performed if there is a blockage in the pharynx or in the upper trachea, or if the patient is having problems with mucus and other secretions getting into the windpipe (trachea). There are many reasons why the pharynx or the upper trachea may be blocked. The patient's windpipe may be blocked by a swelling, by a severe injury to the neck, nose, or mouth, by a large foreign object, by paralysis of the throat muscles, or by a tumor. Patients who need help to breathe may be in a coma, or, because of spinal injury affecting the cervical nerves that control breathing, the patients may need a ventilator to pump air into the lungs for a long time.

Precautions

Doctors perform emergency tracheotomies as last-resort procedures. They are only done if the patient's windpipe is obstructed and the situation is life-threatening.

Emergency tracheotomy

In the emergency tracheotomy, there is no time to explain the procedure or the need for it to the patient. The patient is placed on his or her back with face upward (supine), with a rolled-up towel (if available) between the shoulders. This positioning of the patient makes it easier for the doctor to feel and see the structures in the throat. A local anesthetic (if available, for example in the emergency room of a hospital, but not in a proper operating room) is injected across the cricothyroid membrane. In a setting such as a restaurant, one just cuts, without anesthesia. If the person would otherwise die within five minutes from lack of oxygen, the pain and risks are justified.

Non-emergency (elective) tracheotomy

In a non-emergency tracheotomy, there is time for the doctor to discuss the surgery with the patient, to explain what will happen and why it is needed, and to get the patient's informed consent. The patient is then given anesthesia (sometimes general, sometimes local or topical). The neck area and chest are then disinfected as preparation for the operation, and surgical drapes are placed over the area, setting up a sterile field.

Postoperative care

A chest x ray is often taken, especially in children, to check whether the tube has become displaced, or, of course, in any patient when complications are known to

have occurred. The doctor may prescribe antibiotics to reduce the risk of infection. If the patient can breathe on his or her own, the whole room is humidified; otherwise, if the tracheotomy tube is to remain in place, the air entering the tube from a ventilator is humidified. During the hospital stay, the patient and his or her family members will learn how to handle the problems that the tracheotomy tube causes, including mechanically sucking mucus out of the throat and keeping the tube itself clear. Tracheotomy initially prevents easy swallowing because the larynx is no longer elevated. Secretions are removed by passing a smaller, sterile tube (catheter) into the tracheotomy tube and extending it down into one of the two main bronchi. The tracheotomy tube itself generally requires several cleanings every day. An aseptic, or preferably a sterile, technique must be used. It is important that the skin around the opening (stoma) be carefully maintained to prevent secondary infection and disintegration caused by moisture (such softening and disintegration is called "maceration").

It takes most patients several days to adjust to breathing through the tracheotomy tube. At first, it will be hard even to make non-speech sounds. If the tube allows some air to escape and pass over the vocal cords, then the patient may be able to speak by holding a finger briefly over the tube. A patient on a ventilator will not be able to talk at all.

The tube will be removed if the tracheotomy is temporary. Then the wound will heal quickly, and only a small scar may remain. If the tracheotomy is intended to be permanent, the hole stays open. If eventually it is no longer needed, it will be surgically closed.