A tracheostomy, also known as a tracheotomy, is a medical procedure that involves creating an opening in the neck in order to place a tube into a person’s trachea, or windpipe.
The tube may be temporary or permanent. It’s inserted through a cut in the neck below the vocal cords that allows air to enter the lungs. Breathing is then done through the tube, bypassing the mouth, nose, and throat.
The hole in the neck that the tube passes through is commonly known as a stoma.
Did you know?
The words “tracheostomy” and “tracheotomy” are often used interchangeably.
However, tracheostomy technically refers to the medical procedure itself, while tracheotomy refers to the incision that’s created during the procedure.
A tracheostomy is performed for several reasons. It may be performed during an emergency when your airway is blocked. It could also be performed when a health condition or other issue makes regular breathing impossible.
Conditions or situations that may require a tracheostomy include:
- the need for prolonged respiratory or ventilator support
- congenital abnormalities of the airway
- airway burns from the inhalation of corrosive material
- obstruction of the airway by a foreign object
- obstructive sleep apnea
- injury to the larynx, also known as the voice box
- severe neck or mouth injuries
- bilateral vocal cord paralysis
- facial burns or surgery
- chronic lung disease
- cancers that affect the head and neck
Less common reasons for a tracheostomy include:
- neck tumors
- paralysis of the muscles used in swallowing
- injury to the chest wall
- dysfunction affecting the diaphragm
A doctor might recommend a tracheostomy for a child if they need help breathing or have these other symptoms:
- They require a machine to help their breathing.
- Their airway is too small or blocked.
- They need help removing extra mucus.
- They’re experiencing aspiration, in some cases.
Any medical procedure where the skin is broken carries the risk of infection and excessive bleeding. There’s also a chance of an allergic reaction to anesthesia, although it’s rare. Tell your doctor if you’ve had an allergic reaction to anesthesia in the past.
Risks specific to a tracheostomy include:
- a blocked or dislodged tube, which may cause trouble breathing
- trapped air under the skin
- breakdown of the area around the stoma
- formation of granulation tissue, which is a combination of connective tissue and blood vessels, in the airway
- scar tissue in the trachea
- tracheitis, or an infection of the trachea
- damage to the thyroid gland
- lung collapse
Rare risks include erosion of the trachea and a fistula, which is an abnormal tunnel between two parts of the body.
A fistula, commonly called a tracheoinnominate fistula, may occur between:
- the trachea and the brachiocephalic artery, also known as the innominate artery, of the heart
- the trachea and the esophagus
Babies, people who smoke, and older adults have a greater risk of complications from a tracheostomy.
If your tracheostomy is planned, such as for people having cancer surgery, the doctor will tell you how to prepare. Preparation will involve fasting beforehand.
If your tracheostomy is performed during an emergency, there will be no time to prepare.
How to plan for a hospital stay
If you’re having a planned tracheostomy, there are several things you can do to prepare for your hospital stay.
Planning can help you feel more relaxed and confident before the procedure. It can also help with recovery. Take the following steps:
- Ask your doctor how long you’re expected to be in the hospital.
- Before the procedure, arrange to have someone bring you home from the hospital.
- Get any supplies the doctor says you’ll need after the procedure.
- Consider taking steps to move your body more.
- If you smoke, consider quitting.
- Ask the doctor about possible complications.
For most tracheostomies, you’ll be given general anesthesia. This means you’ll fall asleep and will not feel any pain.
Some people have severe airway problems and cannot be intubated. They’ll undergo a rare procedure known as an awake tracheostomy. In an awake tracheostomy, your airway is kept open by your respiratory drive. You’ll also be injected with local anesthesia.
Anesthesia numbs the area of your neck where the hole is made. The procedure will begin only after the anesthesia has started working and usually takes 20 to 45 minutes.
Surgical tracheostomy includes the steps below:
- While you lie on your back, your doctor will make a cut into your neck just below your larynx. The cut will go through the cartilaginous rings of the outer wall of your trachea.
- The hole is then opened wide enough to fit a tracheostomy tube inside.
- Your doctor may hook the tube up to a ventilator, in case you need a machine to breathe for you.
- The doctor may secure the tube in place with a band that goes around your neck. This helps keep the tube in place while the skin around it heals.
- If you cannot have a band around your neck, the doctor may use sutures to hold the tube in place.
In pediatric tracheostomy
There are some differences between pediatric tracheostomy and tracheostomy in adults. For instance:
- In pediatric tracheostomy, a doctor will often use a scope to confirm the tube is in the right position. A scope is a flexible tube that often has a camera at the end.
- A child undergoing pediatric tracheostomy will often receive stay sutures, which are temporary. The doctor will remove the stay sutures the first time they change the tracheostomy tube.
Percutaneous tracheostomy is minimally invasive but comes with a greater risk of airway damage. This technique includes the steps below:
- Your doctor will pierce the skin below the neck with a needle.
- They will then insert a special wire called a guidewire into the body.
- They will place a different device called a dilator over the guidewire to stretch the opening they’ve created in the trachea.
- They will remove the dilator.
- They will place the tracheostomy tube over the guidewire and use the guidewire to help lower the tube into its proper position. Your doctor may also use a bronchoscope to help view the inside of your body.
- After the tube is in its proper place, they will remove the guidewire.
- As with a surgical tracheostomy, the doctor may hook the tube up to a ventilator.
- The doctor will secure the tube in place using either a band that goes around your neck or sutures.
Percutaneous tracheostomy is rarely performed on children.
Adapting to a tracheostomy tube
It typically takes a few days to adapt to breathing through a tracheostomy tube. It will take about 1 week for the opening to heal. During that time, your doctor may replace the tube.
Talking and making sounds also takes some practice. This is because the air you breathe no longer passes through your larynx. For some people, covering the tube with a small plastic cap or their finger helps them talk.
Alternately, special valves can be attached to the tracheostomy tube. While still taking in air through the tube, these valves allow air to exit the mouth and nose, allowing you to speak.
However, not everyone will be able to tolerate a tracheostomy cap, finger occlusion, or a speaking valve.
Your healthcare team will provide guidance on how to care for your tracheostomy tube so that you can safely maintain it at home. That includes caring for, cleaning, and replacing the tube as well as keeping the skin around the tracheostomy clean and dry.
Cleaning and maintaining the tube
The tracheostomy tube will need to be worn at all times.
A tracheostomy tube typically has three parts:
- The outer cannula keeps your tracheostomy from closing. It always remains in place and should only be removed by a healthcare professional.
- The inner cannula slides in and out. It should be kept in place, except when changed daily to prevent the buildup of dried mucus.
- The tracheostomy band or tie keeps the tube in place by connecting around your neck to the outer cannula. Some tracheostomy ties will have cuffs, which help prevent air from leaking out of the tracheostomy tube.
Most tracheostomy tubes need to be replaced every 1 to 3 months. A respiratory therapist, otolaryngologist (ear, nose, and throat doctor), or another specialist may replace the tube the first time. You and your caregivers can be trained to change the tube.
In pediatric tracheostomy
Most pediatric tracheostomy tubes do not have an outer or inner cannula. This means the tubes get changed more frequently than tracheostomy tubes in adults.
If you have trouble coughing up mucus in your lungs or find it hard to breathe, suction can be used to clear your airway.
Keeping the stoma clean
With clean hands, check your stoma at least once a day for symptoms of infection. That can include swelling, redness, or new or bad-smelling discharge. If you notice any of these symptoms, reach out to your doctor.
Keep your stoma clean by following these steps:
- Using a mirror to help, remove and replace any dressings.
- Gently clean the outer cannula and skin with saline solution and clean gauze or a washcloth.
- Remove any crust or dried mucus.
Activities after the procedure
Your recovery from surgery will be a multi-step process.
Some people with tracheostomies have difficulty speaking. Keeping a pen and paper or whiteboard close by can help with communication.
Many people with tracheostomies can eat without trouble, but some may require help from a speech therapist or nutritionist to relearn how to chew and swallow.
It may take some time to adjust to sleeping with a tracheostomy. A humidifier can help.
If you have severe obstructive sleep apnea and cannot tolerate a continuous positive airway pressure (CPAP) machine or other surgeries, you may actually sleep better with a tracheostomy.
While showering, take steps to keep water from getting into the stoma and tracheostomy tube. That can include:
- lowering the showerhead to low chest height and standing with your back to the water
- using a shower shield
- covering the opening with a waterproof covering.
You can also opt for baths instead.
Slowly increase your physical activity over time. Avoid swimming and situations where you may be submerged in water.
If the condition that prompted your tracheostomy has resolved, the tube may be removed. Reasons your doctor may recommend removing your tracheostomy tube include the following:
- You’re able to breathe independently.
- An injury to the trachea has healed.
- A blockage of the trachea has cleared.
Before removing your tube, your doctor will first ensure that it’s safe to do so. You’ll likely undergo a capping trial.
In a capping trial, you cover the tracheostomy tube with a small cap for increasing periods of time while you’re awake. If it’s easy for you to breathe through your mouth and nose while you wear the cap, then it’s safe for your doctor to remove your tracheostomy tube.
If your tracheostomy is temporary, there’s typically only a small scar left when the tube is removed. If you have a short-term tracheostomy, the stoma will likely close on its own.
A long-term tracheostomy may leave a tracheocutaneous fistula that doesn’t close completely. Those with a permanent tracheostomy will require surgical revision to close the stoma.