Tracheotomy (, UK also ), or tracheostomy, is a surgical airway management procedure which consists of making an incision on the front of the neck to open a direct airway to the trachea. The resulting stoma (hole) can serve independently as an airway or as a site for a tracheal tube (or tracheostomy tube) to be inserted; this tube allows a person to breathe without the use of the nose or mouth.
Etymology and terminology
The etymology of the word tracheotomy comes from two Greek words: the root tom- (from Greek τομή tomḗ) meaning "to cut", and the word trachea (from Greek τραχεία tracheía). The word tracheostomy, including the root stom- (from Greek στόμα stóma) meaning "mouth", refers to the making of a semi-permanent or permanent opening and to the opening itself. Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the stoma (hole) at the time it is created.
Indications There are four main reasons why someone would receive a tracheotomy:
Emergency airway access Airway access for prolonged mechanical ventilation Functional or mechanical upper airway obstruction Decreased/incompetent clearance of tracheobronchial secretions In the acute (short term) setting, indications for tracheotomy include such conditions as severe facial trauma, tumors of the head and neck (e.g., cancers, branchial cleft cysts), and acute angioedema (swelling) and inflammation of the head and neck. In the context of failed tracheal intubation, either tracheotomy or cricothyrotomy may be performed.
In the chronic (long-term) setting, indications for tracheotomy include the need for long-term mechanical ventilation and tracheal toilet (e.g., comatose patients, extensive surgery involving the head and neck). Tracheotomy may result in a significant reduction in the administration of sedatives and vasopressors, as well as the duration of stay in the intensive care unit (ICU). In extreme cases, the procedure may be indicated as a treatment for severe obstructive sleep apnea (OSA) seen in patients intolerant of continuous positive airway pressure (CPAP) therapy. The reason tracheostomy works well for OSA is that it is the only surgical procedure that completely bypasses the upper airway. This procedure was commonly performed for obstructive sleep apnea until the 1980s, when other procedures such as the uvulopalatopharyngoplasty, genioglossus advancement, and maxillomandibular advancement surgeries were described as alternative surgical modalities for OSA. If prolonged ventilation is required, tracheostomy is usually considered. The timing of this procedure is dependent on the clinical situation and an individual's preference. An international multicenter study in 2000 determined that the median time between starting mechanical ventilation and receiving a tracheostomy was 11 days. Although the definition varies depending on hospital and provider, early tracheostomy can be considered to be less than 10 days (2 to 14 days) and late tracheostomy to be 10 days or more.
Alternatives Biphasic cuirass ventilation is a form of non-invasive mechanical ventilation that can — in a small subset of cases — allow people to avoid a tracheostomy.
Components
A tracheostomy tube may be single or dual lumen, and also cuffed or uncuffed. A dual lumen tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. The obturator is used when inserting the tracheostomy tube to guide the placement of the outer cannula and is removed once the outer cannula is in place. The outer cannula remains in place but, because of the buildup of secretions, there is an inner cannula that may be removed for cleaning after use or it may be replaced. Single-lumen tracheostomy tubes do not have a removable inner cannula, suitable for narrower airways. Cuffed tracheostomy tubes have inflatable balloons at the end of the tube to secure them in place. A tracheostomy tube may be fenestrated with one or several holes to let air through the larynx, allowing speech. Special tracheostomy tube valves (such as the Passy-Muir valve) have been created to assist people in their speech. The patient can inhale through the unidirectional tube. Upon expiration, pressure causes the valve to close, redirecting air around the tube, past the vocal folds, producing sound.
Surgical procedure
Open surgical tracheotomy (OST) The typical procedure done is the open surgical tracheotomy (OST) and is usually done in a sterile operating room. The optimal patient position involves a cushion under the shoulders to extend the neck. Commonly a transverse (horizontal) incision is made two fingerbreadths above the suprasternal notch. Alternatively, a vertical incision can be made in the midline of the neck from the thyroid cartilage to just above the suprasternal notch. Skin, subcutaneous tissue, and strap muscles (a specific group of neck muscles) are retracted aside to expose the thyroid isthmus, which can be cut or retracted upwards. After proper identification of the cricoid cartilage and placement of a tracheal hook to steady the trachea and pull it forward, the trachea is cut open, either through the space between cartilage rings or vertically across multiple rings (cruciate incision). Occasionally a section of a tracheal cartilage ring may be removed to make insertion of the tube easier. Once the incision is made, a properly sized tube is inserted. The tube is connected to a ventilator and adequate ventilation and oxygenation is confirmed. The tracheotomy apparatus is then attached to the neck with tracheotomy ties, skin sutures, or both.
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