Tracheostomy ("Trach")

by Dr. Christopher Chang, last modified on 3/18/12
If you like this article, please comment below!
Tweet

When the unthinkable happens to a loved one whether it be an accident or a major illness requiring hospitalization in the ICU (Intensive Care Unit) with a machine breathing for him/her, a procedure called a "tracheotomy" may be brought up at some point by the physicians. This webpage is to explain the why, what, and how of this operation in order to demystify this procedure and allow the caretakers to make an informed decision. In rare cases, patients with severe obstructive sleep apnea unresponsive to all other options may opt for this procedure as well.

Normally, a person breathes air thru the nose and mouth and into the lungs. When a person is "intubated," a tube is placed through the mouth and into the windpipe. A machine is than connected to the tube and "pushes" air through the tube and into the lungs so that the person doesn't have to put any effort into breathing... the machine does all the work of breathing.

WHAT is a Tracheostomy ("Trach")?

In a nutshell, a tracheostomy is a procedure whereby the surgeon makes a small hole in a patient's neck directly into the windpipe (trachea). Through this hole, a very short tube called a tracheostomy tube is inserted from the surface of the neck directly into the windpipe. The tracheostomy tube is usually about 3 inches long.

In cases of severe obstructive sleep apnea (OSA), a trach is the only operation guaranteed to cure a person of OSA.

WHY do a Trach?

Whenever a patient is anticipated to be on a breathing machine (called a ventilator) and intubated (breathing tube through the mouth) for more than 10 days, a tracheotomy is recommended for several reasons:

There may be other reasons as well depending on the particulars of a given patient's illness.

Although this procedure may sound "scary" and many patients and their families automatically refuse to consider such a procedure, the following survey done on February 19, 2008 on physicians nationwide may be illuminating on how worthwhile having this procedure is to recovery. When US physicians were polled at what point they would consider a tracheostomy on themself or their loved one if prolonged intubation was expected, 50% stated trach should be done within the first 8 days of intubation of which 28% wanted it to be performed within 3-5 days. Only 15% would consider a trach after 12 days or longer intubation.

The other fact to consider is that a trach is TEMPORARY!!! Once the patient is strong enough to breath on their own, the trach tube can be removed and the hole in the neck will completely close up within a few weeks without need for another surgical procedure.

How is a Trach Performed?

The trach is performed under general anesthesia and takes about 15 minutes to perform. In essence, a 1.5 inch incision is created in the midline neck directly over the windpipe indicated by the black arrow in the photo. Dissection is carried down to the windpipe and a window created through which a trach tube is inserted.

Watch Video on Tracheostomy

Neck is sterilized with betadine to clean the skin and than draped to prevent any contamination from the environment.

After the incision, underlying fat is removed.

Dissection is carried down to the windpipe which is completely exposed in this picture. One can see the faint outlines of 2 1/2 tracheal rings.

A small window is then created in the windpipe. In this picture, one can see the endotracheal tube inside the windpipe. This tube is slowly removed from the windpipe as the anesthesiologist pulls the tube out from the mouth.

Once the endotracheal tube is removed, the windpipe and surrounding area is completely suctioned of all secretions and blood.

The tracheostomy tube is then inserted and secured in place. That's it!

Trach Care

The skin around the trach tube should be kept clean and clear of any secretions to prevent skin breakdown. At first, lots of suctioning of the trach tube may be required as the patient may be too weak to cough it out. This suctioning is accomplished by threading a soft and flexible tubing through the trach tube and down into the windpipe. Once the suction tube has been inserted, suctioning is performed which removes any accumulated secretions present.

What about Eating?

As long as the cuff of the trach tube is completely deflated, one can eat by mouth just as if the trach is not there.

When Can a Trach be Removed?

A trach can be removed when a patient is able to breath with the trach tube completely plugged so no air passes through it. Prior to plugging the trach, the tube should be swapped out for a smaller size so that air has an easier time moving around it. Once the trach is plugged, air moves the normal way thru the nose and mouth. If the patient has difficulty breathing with the trach plugged, trach removal cannot happen yet.

What Happens After the Trach is Removed?

If the trach is removed within months of placement, the hole will close up on its own over a period of several weeks with an occlusive dressing in place (generally a large band-aid or vaseline gauze covered with gauze and tape). The key thing is to prevent any air leakage when talking or coughing by holding the dressing down. If there is air escape, this will prevent the hole from closing completely, a situation known as tracheo-cutaneous fistula. If the scar is unsightly or there is a persistent fistula, it can be easily corrected surgically which often occurs if the trach is removed years after placement.