Are you wanting to know more about tracheostomies and how they help improve breathing?

We know that it can be challenging to find information on the topic and we would like to help.

This tracheostomy blogpost was written by an otolaryngologist (ear, nose and throat surgeon).

As part of the background for this blogpost, we searched the internet for frequently asked questions and answered them.

The goal of the blogpost is to educate you on tracheostomy and how it improves breathing.

This blogpost provides illustrations that shows the anatomy that demonstrates how tracheostomies can help improve breathing.

Tracheostomy tube in the neck showing airflow. Oxygen in blue is going toward the lungs and carbon dioxide is going away from the lungs. CamachoMD.com
Tracheostomy tube in the neck showing airflow. Oxygen in blue is going toward the lungs and carbon dioxide is going away from the lungs.

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Summary for tracheostomy information:

A tracheotomy is when an opening is made between the airway of the upper neck (trachea) and the skin.

The opening (tracheostomy) allows air to travel between the environment around the person and their airway (trachea and lungs).

By having a tracheostomy, the upper airway is bypassed so that the patient can breathe better. 

Tracheostomies are performed for many reasons, such as emergencies involving the upper airway, long-term ventilation requirements, and cancers of the head and neck.

Tracheostomies were performed routinely as the most definitive treatment for obstructive sleep apnea until the early 1980’s when (continuous positive airway pressure) CPAP was developed.

Although tracheostomies are highly effective for obstructive sleep apnea, they are rarely performed for that purpose today.

Background:

What is a tracheostomy?

Tracheostomies have been documented as early as the BC times. So, in other words, the procedure has been around for over 2000 years.

A tracheotomy is the technical name of the procedure that is used to create an opening or a hole into the neck.

Tracheostomy, on the other hand, is the opening itself or the hole in the neck.

Tracheostomy in the airway showing oxygen coming in and carbon dioxide going out. CamachoMD.com
Tracheostomy in the airway showing oxygen coming in and carbon dioxide going out.

What are the indications for a tracheostomy?

There are many reasons for a tracheostomy to be performed.

The main reason for a tracheostomy is to bypass the structures of the upper airway so that air can get into the lungs without obstruction.

Common reasons for a tracheostomy include:

A severe infection of the airway (epiglottitis or supraglottitis),

Cancer that involves the head and neck (the tracheostomy protects the airway),

Severe laryngomalacia in children (floppy upper airway that obstructs breathing),

Mass or growth in the upper airway,

Foreign body in the upper airway,

A child who has a ball in her throat and it is affecting her breathing. Foreign bodies can be emergency situations. CamachoMD.com
A child who has a ball in her throat and it is affecting her breathing. Foreign bodies can be emergency situations.

Pierre Robin sequence (disorder in which the lower jaw is very small),

Macroglossia (very large tongue which can happen for many reasons),

Head and neck trauma (to protect the airway), and

Patients who cannot be weaned off a ventilator (breathing machine used in the intensive care units).

How small of a tracheostomy tube can be made in order to relieve blockage in the upper airway?

We could not find a single study describing patients with obstructive sleep apnea who were treated with a mini-tracheostomy and had a sleep study before and after the tracheostomy.

However, one study reviewing the literature found that mini tracheostomies as small as 4 mm in size have been used to relieve upper airway obstruction in the short term.[1]

So, hypothetically a 4 mm (mini) tracheostomy could also be used as treatment for obstructive sleep apnea.

When is a tracheostomy needed on an emergent basis?

There are rare situations that a tracheostomy needs to be performed on a more urgent or emergent basis.

Typically, the situations that require an emergency tracheostomy involve a blockage of the upper airway that is significantly affecting the patient’s breathing.

If a patient requires an immediate airway surgery to help them breathe, then a cricothyroidotomy is often preferred as it is a much quicker and less bloody surgery to perform in a true emergency situation.

If a patient is truly urgent or emergent, then an awake tracheostomy can be performed.

In an awake tracheostomy, the patient is taken to the operating room and has surgery while awake (the skin is numbed and the patient is monitored and made as comfortable as possible given the circumstances).

Are there alternatives to an awake tracheostomy?

In some circumstances, the Ear, Nose and Throat surgeon and anesthesia provider may decide that it is safe to attempt an awake intubation.

Awake intubations are usually performed with the patient sitting up and a long flexible scope is placed into the nose and an endotracheal tube is threaded over it so that once the flexible scope is in the airway, the endotracheal tube can be safely guided into the airway.

Upper airway that is normal in appearance. CamachoMD.com
Upper airway that is normal in appearance.

Depending on the circumstances, the patient may be left intubated or a tracheostomy might be performed after the intubation.

Airway in a woman showing that the patient is having a breathing tube placed while awake. the endoscope has a screen that allows you to see the airway. CamachoMD.com
Airway in a woman showing that the patient is having a breathing tube placed while awake. the endoscope has a screen that allows you to see the airway.
Awake patient after placement of breathing tube into her nose while awake. This is done for emergency airway situations. CamachoMD.com
Awake patient after placement of breathing tube into her nose while awake. This is done for emergency airway situations.
Patient who had a breathing tube placed into her nose and she is going to sleep (with anesthetic medications). CamachoMD.com
Patient who had a breathing tube placed into her nose and she is going to sleep (with anesthetic medications).

Where are tracheostomies performed?

Tracheostomies are performed in the operating room.

There are headlights, equipment and a group of team members that help ensure the surgery goes as well as possible.

The team members in an operating room include:

Operating surgeon

Anesthesia provider (anesthesiologist or a certified registered nurse anesthetist (CRNA)),

Operating room (OR) nurse, and a

Surgical technician.

Percutaneous tracheostomies

A percutaneous tracheostomy can be performed in the intensive care unit.

How are tracheostomies performed?

Traditional tracheostomy in the operating room

The following is a step-by-step description of how a tracheostomy is performed:

First, the OR nurse, the anesthesia provider and the operating surgeon will meet the patient or the family to obtain consent (permission) to do the procedure.

Second, once consent is obtained, the patient is taken to the operating room.

If the patient is going to have an awake tracheostomy, the steps are generally the same, except that there is no intubation required.

For patients who are not having an awake tracheostomy, the next step is for the patient lie down on the operating room table.

Tracheostomy tube in the neck showing airflow. Oxygen in blue is going toward the lungs and carbon dioxide is going away from the lungs. CamachoMD.com
Tracheostomy tube in the neck showing airflow. Oxygen in blue is going toward the lungs and carbon dioxide is going away from the lungs.

Once lying down, the anesthesia provider will give the patient oxygen and will then intubate the patient using a laryngoscope (instrument with a light that allows them to see down to the vocal cords so the endotracheal tube (breathing tube) can be placed).

If the patient is intubated already, such as in the case of a ventilator dependent patient from the ICU, then the procedure can start as below.

The patient is kept on the ventilator to allow for the machine to breathe for them throughout the procedure.

The surgeon then identifies and marks the landmarks of the neck.

Local anesthetics are placed where the skin will be cut to minimize any pain.

A small, but sharp, knife is then used to make a cut into the skin just superficial to where the airway will be cut into.

Once the skin is incised, the tissue (fat, muscles, sometimes the thyroid gland), will be cut and gently moved away from the front of the airway (trachea).

Once the trachea is encountered, the anesthesia provider will then lower the oxygen level to room air to help minimize the chance of having an airway fire.

Once the oxygen is to room air, an incision is made into the trachea (typically between tracheal rings 2 and 3 or between tracheal rings 3 and 4). The specific location will be based on the patient’s anatomy and surgeon preference.

Sometime an extra step is taken and the sides of the tracheal incision might be extended vertically up and down, creating the shape of an H (called a Bjork flap).

If this extra step is taken, then the trachea is sutured above and below the horizontal incision, and this allows the trachea to be sutured to the skin (creating a more secure airway).

The tracheostomy tube is then placed into the trachea and the cuff on the tube is inflated and the patient is then placed onto the ventilating machine.

If the ventilation is good, then the tracheostomy tube is secured to the patient using sutures and/or tracheostomy ties.

In the early phases, it is important that the tracheostomy tube be kept secured to the airway in this fashion to help minimize the chance of the tube coming out accidentally.

Accidental decannulation (tracheostomy tube falling out of the airway) can be detrimental in the early days after placement of the tracheostomy tube.

Is there a way to do a tracheostomy without having to go to the operating room?

Percutaneous tracheostomies can be performed outside the operating room.

The advantage is that the patient does not need to go to the operating room and can have the procedure at the bedside.

Using the technique, there is a skin incision, but the remainder of the surgery could be done without sharp instrumentation.

In general, the steps for a percutaneous tracheostomy include:

Numbing medication (local anesthetic such as 1% lidocaine) is injected over the planned neck incision,

The skin incision is made anterior to where the tracheostomy is going to be placed,

The tissue in front of the trachea is then pushed out of the way using blunt (not sharp) instruments.

A scope (flexible or rigid bronchoscope) is placed into the airway and the endotracheal tube is moved back slightly or entirely depending on the plan,

Once the airway is suctioned and the trachea can be visualized, a needle with its catheter is introduced into the trachea (between tracheal rings 1 and 2 or tracheal rings 2 and 3),

The needle is removed and the catheter is left in the airway,

A guidewire is then placed through the catheter and the trachea is serially dilated (using airway dilators from the special kit) so that the tracheostomy tube can fit in the hole,

The tracheostomy is visualized through the airway and then is secured with sutures and cotton straps.

Is there a way to perform a permanent tracheostomy?

Yes, if a patient needs a tracheostomy permanently, then there are techniques to remove some of the fat from the neck and then suture the airway to the skin in a manner that makes it a permanent hole without the need for a tracheostomy tube.[2]

Is there a difference in the location of the tracheostomy for patients who have a percutaneous tracheostomy vs. a traditional tracheostomy?

Yes, a percutaneous tracheostomy is typically performed between tracheal rings 1 and 2 or tracheal rings 2 and 3. 

While a traditional tracheostomy that is performed in the operating room is typically performed between tracheal rings 2 and 3 or tracheal rings 3 and 4.

Ultimately, the decision for the location is based on many factors such as the anatomy of the patient, whether there is a lot of neck fatty tissue, the location of the thyroid gland (isthmus connects the right and left sides of the thyroid gland and can sit in the way of the tracheostomy incision site) and surgeon preference.

What is a Passy Muir valve and does it allow for speech with a tracheostomy?

Passy muir valve in a woman with a tracheostomy. The valve is shown in purple (covering the tracheostomy tube) and it allows for air to go out the nose and mouth (for speech). CamachoMD.com
Passy muir valve in a woman with a tracheostomy. The valve is shown in purple (covering the tracheostomy tube) and it allows for air to go out the nose and mouth (for speech).

A Passy Muir valve is a cover that is placed over the tracheostomy tube opening that is a one way valve. This allows for the patient to breathe into the neck and then breathe out the nose or mouth.

If a patient has a Passy Muir valve in place, then they can usually speak if their vocal cords and upper airway anatomy allows for speech.

When should patients not have a tracheostomy?

There are circumstances when a tracheostomy might not be recommended.

If the patient is in the intensive care unit and is requiring high pressures in order to maintain ventilation, then a tracheostomy might not be a good choice. 

The reason is that an endotracheal tube can ventilate patients better than a tracheostomy can when the pressure requirements are high in the patients.

If an intubated patient is significantly dependent on oxygen in order to maintain their body’s oxygen at a normal level, then the surgery will be more challenging because the use of electrocautery (electrical tool that stops bleeding) might be contraindicated during the surgery.

What happens after a tracheostomy?

The upper airway is no longer obstructed in patients after a tracheostomy. Therefore, the breathing should be dramatically improved if the patient is not on a ventilator.

Care has to be taken to make sure that the tracheostomy stays in the airway and also that the secretions in the airway are suctioned away especially the first few weeks after the surgery.

For patients who are on a ventilator, the amount of sedation can usually be reduced after the procedure.

What are the potential complications after a tracheostomy?

Airway obstruction and bleeding are the two major possible complications after a tracheostomy.

Complications in general include:

  • Granulation tissue,
  • Displacement of the tracheostomy tube,
  • Granuloma formation,[3]
  • Stenosis of the tracheostomy stoma (narrowing of the hole in the neck),[3]
  • Bleeding from the stoma (opening to the trachea),[4]
  • Infection at the site of the stoma,[4]
  • Potential stenosis of the trachea over time,[4]
  • Scar formation at the site of the stoma,[4]
  • Bleeding at other sites in the trachea, either minor or catastrophic, and
  • Death.[4]

What are problems that led to death in patients based on autopsies?

Although death is rare, it is a very real and scary possibility.

A review by Byard and colleagues[5] found the following problems were associated with death:

  • Incorrect positioning of the tracheostomy tube,
  • Perforation of the trachea with a pneumothorax,
  • Necrosis of the trachea from the tracheal cuff being at too high of a pressure,
  • Plugging of the tracheostomy tube with mucous,
  • Accidental loss of the tracheostomy tube (falling out of the airway), and
  • Fistula (connection) that forms between the trachea and a blood vessel (such as a trachea innominate artery fistula).[5]

Can tracheostomy improve obstructive sleep apnea?

Yes, tracheostomies can help dramatically improve obstructive sleep apnea.

Are tracheostomies used for adults with obstructive sleep apnea?

In adults,[6] tracheostomy has improved sleep apnea dramatically. The apnea index (complete blockage of the airway) decreased from 73 to 0.2 events per hour.[6] 

Interestingly, the apnea-hypopnea index (complete and partial obstructions) decreased from 92 to 17 events per hour, which means that patients still had post-operative moderate obstructive sleep apnea.[6] 

The theory is that the fatty tissue in the neck partially folds over the tracheostomy opening, therefore causing a persistence in the obstructive sleep apnea in the form of hypopneas (partial obstruction of the opening of the tracheostomy tube).[6]

Are tracheostomies used for children with obstructive sleep apnea?

Fray and colleagues reviewed the literature and found that tracheostomies significantly improved obstructive sleep apnea in children; however only three patients had sleep study data before and after the tracheostomy (97% reduction in the apnea hypopnea index and a 98% reduction in the apnea index).[7]

Are tracheostomies used for morbidly obese patients with obstructive sleep apnea?

There has been a dramatic reduction in the apnea-hypopnea index from 64 events per hour to 2 events per hour from tracheostomy in morbidly obese patients.[8]

Government Disclaimer: The views expressed in this website are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

References:

1.            Camacho M, Zaghi S, Chang ET, Song SA, Szelestey B, Certal V. Mini Tracheostomy for Obstructive Sleep Apnea: An Evidence Based Proposal. Int J Otolaryngol. 2016;2016:7195349.

2.            Akst LM, Eliachar I. Long-term, tube-free (permanent) tracheostomy in morbidly obese patients. Laryngoscope. 2004;114(8):1511-1512; author reply 1512-1513.

3.            Conway WA, Victor LD, Magilligan DJ, Jr., Fujita S, Zorick FJ, Roth T. Adverse effects of tracheostomy for sleep apnea. JAMA. 1981;246(4):347-350.

4.            Engels PT, Bagshaw SM, Meier M, Brindley PG. Tracheostomy: from insertion to decannulation. Can J Surg. 2009;52(5):427-433.

5.            Byard RW, Gilbert JD. Potentially lethal complications of tracheostomy: autopsy considerations. Am J Forensic Med Pathol. 2011;32(4):352-354.

6.            Camacho M, Certal V, Brietzke SE, Holty JE, Guilleminault C, Capasso R. Tracheostomy as treatment for adult obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope. 2014;124(3):803-811.

7.            Fray S, Biello A, Kwan J, Kram YA, Lu K, Camacho M. Tracheostomy for paediatric obstructive sleep apnoea: A systematic review. J Laryngol Otol. 2018;132(8):680-684.

8.            Camacho M, Teixeira J, Abdullatif J, et al. Maxillomandibular advancement and tracheostomy for morbidly obese obstructive sleep apnea: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2015;152(4):619-630.