Tracheostomy Surgery : Procedure & Aftercare

Overview

A tracheostomy is typically performed in situations where there is a blockage or obstruction in the upper airway, or when a person is unable to breathe effectively on their own due to various medical conditions. Here, a neck incision is made leading to the trachea (windpipe). The opening is used to fit in a tracheostomy tube that will help maintain the airway and assist in breathing.

What is Tracheostomy?

A tracheostomy is a scheduled surgical procedure whereby an opening (stoma) is made in the neck directly into the trachea (windpipe). A tube is inserted directly into the opening to allow breathing. Therefore, the primary purpose of the procedure is to bypass any obstruction in the upper airway and gain direct access to the trachea. It may be performed in cases where a person needs long-term mechanical ventilation, such as individuals with severe respiratory conditions or those recovering from certain surgeries.

When is Tracheostomy Recommended?

Tracheostomy is recommended in various clinical scenarios, including:

• Airway Obstruction: Conditions such as tumors, severe infections, trauma, or congenital anomalies often obstruct the airway.
• Prolonged Ventilation: Those who are suffering from neuromuscular diseases or individuals who require prolonged mechanical ventilation can secure the airway with tracheostomy. 
• Protection of the Airway: In patients who are unable to clear the respiratory secretions by themselves, tracheostomy will help in maintaining airway hygiene.
• Chronic Pulmonary Diseases: It is used in case of chronic pulmonary diseases, such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, bronchiectasis, and severe dysplasia to clear the airway.
• Neuromuscular Disorders: Neuromuscular disorders such as amyotrophic lateral sclerosis (ALS) and myasthenia gravis may lead to respiratory muscle weakness, necessitating tracheostomy for long-term support.
• Surgical Procedures: May need a temporary tracheostomy after surgical procedures in the laryngeal or pharyngeal region. 
• Burns or Inhalation Injuries: Burns in the neck region can lead to swelling and damage to the airway. Tracheostomy can be of help in such cases.

How to Prepare for Tracheostomy?

To guarantee the safety and effectiveness of the surgery, various actions must be taken in the lead-up to a tracheostomy:

• Medical Evaluation: A thorough evaluation of the medical history and a complete examination will be conducted, with a particular focus on the upper airway and neck.
• Diagnostic Tests: A variety of tests will be needed before the procedure. Common tests include imaging studies or pulmonary function tests, to assess respiratory function.
• Consent: The surgeon or pulmonologist will explain the procedures, including the benefits, risks, and alternatives, and requires your written informed consent. 
• Fasting: It is necessary for all patients to have an empty stomach at the time of tracheostomy. This is to avoid passing food or stomach contents into the breathing tubes during the surgery.
• Discuss Risks and Benefits: Have a detailed discussion with your healthcare team about the reasons for the tracheostomy, potential risks and benefits, and alternative options.
• Clarify Expectations: Understand the expected duration of the tracheostomy, the need for post-operative care, and potential complications.
• Discuss the Type of Anesthesia: The type of anesthesia used for the surgery can depend on the type of tracheostomy and the surgeon’s preference. Often the surgeries can be done under local anesthesia (injected around the surgical area), regional anesthesia (numbing the surgical area by an injection near the nerves), or both.
• Preoperative Medications: Preoperatively, a single dose of preoperative antibiotics may be administered within 60 minutes of the surgical incision to reduce the risk of infection. All medications that affect blood clotting should be stopped before the operation until your doctor tells you to start taking them again.
• Positioning: The patient is placed supine. Neck hyperextension is best for the anterior approach to have good access to the trachea.
• Skin Preparation: The area will be cleaned and sterilized with an antiseptic solution. Any hair will be removed with the use of clippers if required.
• Equipment Check: Proper functioning of all equipment that might be used in case of emergency (tracheostomy tubes, oxygen, suction devices, tracheostomy tube tapes, tracheostomy tube holders) is checked, and made sure that they are available in an emergency. Emergency airway oral and nasal intubation trays should be ready for immediate use.
• Respiratory Therapy: If the patient is already on mechanical ventilation, the RT comes with the patient and before the process starts the RT ensures that there is no problem and the patient’s oxygenation can be maintained throughout the process.

How is Tracheostomy Performed?

Tracheostomy is carried out by a qualified surgeon, frequently with the aid of an anesthesiologist and occasionally a respiratory therapist. Here is a detailed explanation of the normal steps involved in performing a tracheostomy:

• Positioning: The patient is placed on his back (supine position) with the neck extended slightly, which arches the back, in order to better expose the neck. 
• Sterilization: The neck (surgical field) is cleaned with a mild antiseptic solution and draped with sterile linen towels, which leaves only the area of the surgical site visible.
• Incision: The surgeon makes a horizontal (transverse) incision on the neck, usually between the second and third rings of the trachea, although this can differ depending on the patient’s anatomy and the specific reason for the tracheostomy.
• Dissection: The skin, subcutaneous tissue (the tissue beneath the skin, including the major nerves and blood vessels), and the muscles are carefully and systematically dissected to expose the trachea.
• Tracheal Opening: After the trachea is brought to the surface, the surgeon will make an approximately 2-centimeter vertical incision between the tracheal rings. With the tracheal rings lifted into the surgical field with stay sutures, an incision should be made between the second and third or the third and fourth rings. 
• Tube Insertion: A tracheostomy tube is carefully inserted into the tracheostomy opening to establish a patent airway. The tube may have an inflatable cuff that is inflated to create a seal within the trachea, preventing air leakage.
• Securing the Tube: After the tracheostomy tube is inserted, it is secured using either sutures or ties. The tracheostomy tube is taped in place to prevent it from moving.
• Oxygen and Ventilation: Once the tracheostomy tube is inserted, the ventilator tubing is then attached to the tracheostomy tube or, in some cases, oxygen is delivered via the attached oxygen source. 
• Dressing: Dressing: The bedside nurse will place a sterile dressing around the tracheostomy tube.
• Chest X-ray: In some cases, a chest X-ray is taken after the tracheostomy to check where the tracheostomy tube is positioned and to assess lung condition.

Recovery and Aftercare Following Tracheostomy

Recovery

• Observation: Initial hours after tracheostomy should be bountifully observed by direct observation of the vital signs, the pulse oximeter, and the tracheostomy site.
• Pain Control: Pain management strategies are employed to keep the patient comfortable. This may include pain medications administered intravenously or through other routes.
• Breathing: The medical team will confirm that the tracheostomy tube remains in place and that there is no bleeding or air leakage. 
• Observe for swelling: Make sure that there is no swelling of the neck or surrounding the tracheostomy site.
• Speaking: Some patients may be unable to speak initially. This limitation typically resolves within a matter of days to weeks as the patients become more comfortable and learn techniques to vocalize.

Aftercare

• Cleaning: Establish a routine for daily tracheostomy care, including suctioning, cleaning, and checking the tracheostomy tube for proper placement. Regularly monitor the skin around the tracheostomy site for signs of irritation or infection.
• Tube Care: The patient should return for routine appointments. The tracheostomy tube will need periodic changing and cleaning.
• Humidification: Use a humidifier to add moisture to the air entering the tracheostomy, especially in dry or cold environments.
• Speech: A speech therapist will be available to assist with speaking techniques for patients who have received a tracheostomy.
• Diet: Your doctor will give you specific dietary instructions. You will be able to incorporate solid food into your diet gradually.
• Check-ups: Regular medical visits to check on the health of the tracheostomy site, the tube, and the patient as a whole.

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