Introduction
The respiratory system comprises the upper airway and the lower airway. The nose, mouth, throat, and larynx constitute the upper airway. The windpipe (trachea), air tubes (bronchi), and air sacs (alveoli) comprise the lower airway. The trachea carries oxygen-rich air to the lungs. A tracheostomy is done, and a tracheostomy tube is placed when an individual is on a ventilator for a long time or as an emergency procedure when the airway is suddenly blocked.
What Is Tracheostomy?
Tracheostomy is a surgical procedure in which an opening called a stoma is created in front of the neck below the larynx, and a curved plastic tube called a tracheostomy tube is inserted into the stoma. It is performed as an open surgical tracheostomy or percutaneous dilational tracheostomy.
Why Is Tracheostomy Done?
Tracheostomy is performed to manage airway obstruction and secretions, to reduce the anatomic dead space, and for weaning from mechanical ventilation in patients with chronic respiratory failure.
Tracheostomy is required in the following conditions:
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Medical conditions that require a ventilator (breathing machine) for a long time, more than one or two weeks;
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Conditions like vocal cord paralysis or throat cancer that block or narrow the airway;
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Paralysis or other conditions that disrupt the ability to cough up secretions from the throat and require suctioning to clear the airway;
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In head and neck surgeries, to assist breathing during recovery;
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Severe injury to the head and neck that obstructs breathing;
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In emergency situations, when breathing is blocked, it is not possible to put a breathing tube through the mouth.
What Are the Complications of Tracheostomy?
Complications are life-threatening and occur either during the procedure or later after the procedure.
Immediate complications are:
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Damage to the trachea, thyroid gland, or adjacent nerves.
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Bleeding.
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Wrong placement of the tracheostomy tube or displacement of the tube.
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Air traps under the skin of the neck (subcutaneous emphysema) and causes breathing difficulties and damage to the trachea and food pipe.
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Pain, breathing difficulties, or lung collapse due to the build-up of air between the chest wall and lungs (pneumothorax).
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Formation of blood clots in the neck (hematoma), which compresses the trachea and results in breathing difficulties.
If the tracheostomy tube is in place for a long time, these complications may occur;
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Obstruction of the tube.
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Displacement of the tube.
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An abnormal connection develops between the trachea and the esophagus (tracheoesophageal fistula) and causes the fluids or food to enter the lungs.
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An abnormal connection develops between the trachea and the large artery supplying the right arm and the right side of the head and neck (tracheoinnominate fistula), resulting in life-threatening bleeding.
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Infection around tracheostomy or infection in the trachea and the lungs.
What Is a Tracheostomy Tube?
A tracheostomy tube is an angled or curved tube made from polyvinyl chloride (PVC), silicone, or polyurethane. They are inserted into the stoma created during tracheostomy. The tube consists of three parts; an outer cannula with a flange, an inner cannula, and an obturator.
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The outer cannula is the outer tube with a neck plate that extends from the sides of the outer tube. It holds the tracheostomy and has holes to tie around the neck. The inner cannula is present inside the outer cannula with a lock to prevent dislodgement during coughing and for removal during cleaning.
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The obturator is present inside the tube and has a smooth surface that guides the placement of the tube.
What Are the Types of Tracheostomy Tubes?
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Single and Dual Cannula Tubes - A non-fenestrated single cannula tube with an air-filled cuff is suitable for temporary tracheostomy. Dual cannula tubes are safer because they can be quickly removed during obstruction and are suitable for patients who require tracheostomy tubes even after discharge.
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Fenestrated Tubes - Fenestrated tubes promote air flow and speech. Non-fenestrated tubes are used for suctioning the secretions. Surgical emphysema is common in non-fenestrated tubes also, so fenestrated tubes are not recommended in the newly formed stoma. It is used only during weaning from ventilation, where the wound has healed sufficiently.
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Cuffed Tubes - They are used to maintain a closed circuit for ventilation. The cuff pressure is maintained between 25 to 34 cm H20 to prevent tracheal wall injury and aspiration.
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Uncuffed Tubes - They are used for patients who can manage on their own. Patients with adequate cough reflexes can remove their secretions. This prevents tracheal damage due to inflation and helps in swallowing and communication with the help of a speaking valve. A dual cannula is preferred because removal for cleaning does not cause any trauma.
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Standard and Longer Tubes - They are available in standard and long lengths. Standard tubes are short and angulated. They are not suitable for patients under critical care but are designed for patients with normal airway anatomy. Longer tubes have a fixed or adjustable flange. Fixed-length tubes can be elongated between the stoma and the trachea or within the trachea. A flexible tube with an adjustable flange has a lock for the neck flange and is not suitable for long-term use. A dual cannula fixed longer-length tubes with adequate extensions are more comfortable.
What Are the Uses of Different Types of Tubes?
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Cuffed Tube With Reusable and Disposable Inner Cannula - It is used to maintain a closer circuit for ventilation.
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Cuffless Tube With Reusable and Disposable Inner Cannula - They are used in patients with tracheal problems and for those who are ready for decannulation.
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Fenestrated Cuffed and Cuffless Tubes - They are used in patients who cannot speak with the speaking valve.
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Non-Fenestrated Tubes - They are used to suction the secretions.
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Metal Tracheostomy Tube - They are made of silver or stainless steel. Metal tubes are durable, inhibit bacterial growth, are non-reactive, easier to clean, and can be sterilized. But they are not used frequently because they are rigid, expensive, and lack a connector.
Conclusion
Tracheostomy is a safe and effective procedure performed to relieve airway obstruction and facilitates liberation from prolonged mechanical ventilation, and improves the ability to mobilize the patients. They are temporary or permanent. The patient and the caregiver should be educated about the care for tracheostomy tubes to minimize the risks.
