Definition and Overview

Tracheostomy is a surgical procedure that involves creating a hole in the windpipe or trachea to insert a tube in cases when the patient is having breathing difficulties and suffering from a huge drop in oxygen level or has respiratory failure.

The trachea is a long hollow tube that connects the pharynx and larynx to the lungs. Its main function is to ensure proper airflow as a person inhales and exhales.

It is composed of four different layers. The deepest is called the mucosa, which is responsible for catching any debris that gets into the air passage that may irritate or infect the lungs. Above it is the submucosa, where the blood vessels and nerves can be found. It is also made up of elastin and collagen, which helps stretch the trachea. Around it is the hyaline cartilage, which supports and protects the rings that make up the trachea. Although flexible, it is tough enough to resist any damage due to stresses. On the topmost is the adventitia, which attaches the trachea to the surrounding tissues.

Problems to the trachea, which may affect any of these layers, may cause serious complications, including difficulty in breathing, a huge drop of oxygen level going to the lungs, and respiratory failure. To avoid these, one of the first lines of treatment is tracheostomy.

Tracheostomy may be planned or emergency. When it is planned, general anaesthesia is provided to minimize patient's movement while being operated on. However, when it's a critical situation, local anesthesia is usually administered and the tube is immediately connected to a ventilating machine. Planned tracheostomy can also be percutaneous dilation tracheostomy (PDT), which is carried out at the patient's bedside in an intensive care unit. It is considered as a minimally invasive procedure since only a small incision and needle are needed.

The types of tubes used depend on the purpose of the procedure. However, the design of a specific tube should be the same regardless of the manufacturer.

Who should undergo and expected results

The following scenarios require tracheostomy:

  • There's a foreign body obstructing the windpipe – This happens when an object or a mass (such as a benign or malignant tumour) is lodged in the trachea, which can significantly decrease the person's ability to breathe properly.
  • The presence of trauma-related complicationsTrauma or injuries to the neck and upper back due to violence or accident, for instance, may suddenly cut off the oxygen supply and create an obstruction in the windpipe. Serious burns in the neck can also be classified as emergencies.
  • The patient is about to undergo or has undergone an operation on the larynx or pharynx – Tracheostomy may be carried out before the operation to ensure consistent oxygen supply to the body. The tubes may also be attached while these organs are still healing.
  • There is an inflammation of the trachea – Infection to the trachea may be caused by a virus, bacteria, or foreign object that irritates the tissues. The windpipe can then become inflamed, narrowing the passageway of the air in the process.
  • The mouth or nose is injured – Although the nose is often the organ associated with breathing, the mouth is also an alternative. If any of these organs is having problems, the trach tube can provide the necessary support for a proper airflow. If both are damaged, the tube can be connected to an artificial source of oxygen.
  • There's a congenital defect – The formation of the trachea may be incorrect or there are already issues with the respiratory system as soon as the baby is born. The tube can help increase the survival rate of the infant until such time that the abnormality can be corrected.


A tube is also needed to:

  • Remove the buildup of mucus, secretion, or fluid in the windpipe
  • Support weakened lungs or diaphragm
  • Reinforce breathing for patients under coma
  • Correct sleep apnoea


Tracheostomy may be temporary or permanent. It can also be short or long term, depending on the patient's unique circumstances.

The addition of the tube may be difficult for some patients. It can take at least 3 days before they can get used to it and master breathing through it. They may also have to undergo therapy to help them regain certain normal activities, such as talking and swallowing. It's normal for patients to lose the ability to speak during the first few days after the surgery.

How the procedure works

If it is a planned but open tracheostomy, general anaesthesia is applied followed by local anesthetic to minimize the pain in the area. A large incision or cut is made in the neck, near the throat to access the cartilage rings that protect the trachea. Once the hole is made, the tube is inserted into the hole all the way to the windpipe.

In a PDT, a probe known as an endoscope can be used. This device is equipped with a camera that sends live images of the trachea to a computer screen while the accompanying light tip makes the part more visible. The endoscope then serves as a guide for the surgeon during the procedure. General anesthesia is also used. The procedure, however, is not recommended for people who are obese, especially those who have thick layers of fat in the neck, as well as children who are below 12 years old.

In PDT, a small incision is made in the throat while a small needle is used to create a hole wherein the tube is inserted or introduced into the windpipe. Since the incision is only small, the risk of the patients suffering from surgical infection or injury will be minimized. Recovery and downtime will also be faster.

Possible risks and complications

As with any surgical procedure, the patient who has undergone tracheostomy may develop infection, scarring, and profuse bleeding. The patient may also have a negative reaction to the tube or medications used. The procedure may also cause injury to the nerves, which may lead to paralysis.

References:

  • Goldenberg D, Bhatti N. Management of the impaired airway in the adult. In: Cummings CW, Flint PW, Haughey BH, et al, eds. Otolaryngology: Head & Neck Surgery. 4th ed. Philadelphia, Pa: Mosby Elsevier; 2005:chap 106.
  • Neacy KA. Tracheostomy care. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia, Pa: Saunders Elsevier;2009:chap 7.
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